Provider Demographics
NPI:1588815518
Name:KOSIBA, REGINA ANNETTE (RD, LD)
Entity Type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:ANNETTE
Last Name:KOSIBA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 SHINNECOCK HILLS LN APT 532
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-7416
Mailing Address - Country:US
Mailing Address - Phone:404-247-5219
Mailing Address - Fax:
Practice Address - Street 1:909 SHINNECOCK HILLS LN APT 532
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-7416
Practice Address - Country:US
Practice Address - Phone:404-247-5219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003332133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered