Provider Demographics
NPI:1346799558
Name:GABBARD, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:GABBARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GABBARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:432 MARBELLA LN
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-2128
Mailing Address - Country:US
Mailing Address - Phone:707-685-7615
Mailing Address - Fax:707-685-7615
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-1838
Practice Address - Fax:877-711-7930
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL716771133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered