Provider Demographics
NPI:1578766754
Name:CULBERTSON, GILLIAN M (RD)
Entity Type:Individual
Prefix:MS
First Name:GILLIAN
Middle Name:M
Last Name:CULBERTSON
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 1:2727 MC CLELLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1626
Mailing Address - Country:US
Mailing Address - Phone:417-781-2727
Mailing Address - Fax:417-659-6545
Practice Address - Street 1:2727 MC CLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1626
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:417-659-6545
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005032292133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO350558003Medicaid
OK200079340AMedicaid