Provider Demographics
NPI:1952280794
Name:GUNDERSON, CARLY (MS, RD, CDCES)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:MS, RD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 N ALBINA AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2671
Mailing Address - Country:US
Mailing Address - Phone:856-630-7684
Mailing Address - Fax:
Practice Address - Street 1:2211 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2742
Practice Address - Country:US
Practice Address - Phone:360-487-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61352146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered