Healthcare Provider Details

I. General information

NPI: 1871807776
Provider Name (Legal Business Name): LINDA R GWALTNEY MS RD LD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5909 U S HIGHWAY 49 SUITE 30
HATTIESBURG MS
39402-2860
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-296-2780
  • Fax: 601-296-2781
Mailing address:
  • Phone: 601-296-2780
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002453
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD0251
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: