Provider Demographics
NPI:1821279522
Name:GLUSENKAMP, LILLIAN AINSWORTH (RD)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:AINSWORTH
Last Name:GLUSENKAMP
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:GERTRUDE
Other - Middle Name:
Other - Last Name:GLUSENKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1421 JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2928
Mailing Address - Country:US
Mailing Address - Phone:662-251-6896
Mailing Address - Fax:
Practice Address - Street 1:1421 JOLLY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2928
Practice Address - Country:US
Practice Address - Phone:662-251-6896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered