Healthcare Provider Details

I. General information

NPI: 1669764395
Provider Name (Legal Business Name): BALEANA WATTS MCGILBERRY RDN, LDN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 NOTTINGHAM DR
SEMMES AL
36575-8218
US

IV. Provider business mailing address

4110 NOTTINGHAM DR
SEMMES AL
36575-8218
US

V. Phone/Fax

Practice location:
  • Phone: 251-459-0695
  • Fax: 251-459-0695
Mailing address:
  • Phone: 251-459-0695
  • Fax: 251-459-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number917122
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number917122
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number917122
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number917122
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: