Provider Demographics
NPI:1497923148
Name:GIBBS, LISA M (MS,RDLDN,CNSC,CSO)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MS,RDLDN,CNSC,CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CROCKETT RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1351
Mailing Address - Country:US
Mailing Address - Phone:508-383-1140
Mailing Address - Fax:
Practice Address - Street 1:99 CROCKETT RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1351
Practice Address - Country:US
Practice Address - Phone:508-561-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA328133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered