Provider Demographics
NPI:1932489275
Name:GIBBONS, ROSANNA B (R D)
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:B
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 LOWER GLENCOE ROAD
Mailing Address - Street 2:
Mailing Address - City:SPARKS GLENCOE
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9466
Mailing Address - Country:US
Mailing Address - Phone:410-472-3274
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS ROAD
Practice Address - Street 2:SUITE 360 PAVILION 1
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093
Practice Address - Country:US
Practice Address - Phone:410-583-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDN00220133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist