Healthcare Provider Details

I. General information

NPI: 1154491058
Provider Name (Legal Business Name): THERESA LYNN GILBERT R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGARMAPLE RD 88 MEDICAL GROUP SGQD
WRIGHT PATTERSON AFB OH
45433
US

IV. Provider business mailing address

1557 LANGDON DR
CENTERVILLE FINANCE OH
45459-5006
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9069
  • Fax:
Mailing address:
  • Phone: 937-648-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5857
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: