Healthcare Provider Details

I. General information

NPI: 1659259364
Provider Name (Legal Business Name): AMANDA MEE GIBBS MS RD CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 PARK ST
MALONE NY
12953-1244
US

IV. Provider business mailing address

PO BOX 175
RAY BROOK NY
12977-0175
US

V. Phone/Fax

Practice location:
  • Phone: 315-406-6217
  • Fax:
Mailing address:
  • Phone: 315-406-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number008919
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008919
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: