Provider Demographics
NPI:1639330731
Name:GIBSON, AMANDA J (RD, LD/N)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 KATRINA CT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-2549
Mailing Address - Country:US
Mailing Address - Phone:813-465-2950
Mailing Address - Fax:
Practice Address - Street 1:503 KATRINA CT
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-2549
Practice Address - Country:US
Practice Address - Phone:813-465-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2501133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered