Healthcare Provider Details

I. General information

NPI: 1982761433
Provider Name (Legal Business Name): GWENDOLYN JANE KOSSICK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 MARTHA BERRY BLVD NW
ROME GA
30165-1625
US

IV. Provider business mailing address

1825 MARTHA BERRY BLVD NW
ROME GA
30165-1625
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-8129
  • Fax: 706-238-8037
Mailing address:
  • Phone: 706-295-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD003370
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: