Healthcare Provider Details

I. General information

NPI: 1083775365
Provider Name (Legal Business Name): GAIL PROSSER RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA GAIL PROSSER RD, CDE

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 OLD REDWOOD HWY DEPT OF PEDIATRICS
SANTA ROSA CA
95403-1719
US

IV. Provider business mailing address

3925 OLD REDWOOD HWY DEPT OF PEDIATRICS
SANTA ROSA CA
95403-1719
US

V. Phone/Fax

Practice location:
  • Phone: 707-566-5358
  • Fax: 707-566-5292
Mailing address:
  • Phone: 707-566-5358
  • Fax: 707-566-5292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number017009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: