Provider Demographics
NPI:1346427341
Name:GIBSON, GRACE ANN (RD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301-6 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:97 GREAT TEAYS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9816
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-760-3618
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010676Medicaid
WV001998725OtherMS BCBS
WV1346427341Medicaid
WVGI2030591Medicare PIN
2030592Medicare PIN
2030594Medicare PIN
WVGIMT03991Medicare PIN
WV001998725OtherMS BCBS
WV3810010676Medicaid
2030597Medicare PIN
2030595Medicare PIN