=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114743010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN PHILLIPS GIBSON RPH, NUTRITIONIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1004 WINDERMERE AVE
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-243-7135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1004 WINDERMERE AVE
-----------------------------------------------------
City | MENLO PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94025-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-243-7135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835G0303X
-----------------------------------------------------
Taxonomy Name | Geriatric Pharmacist
-----------------------------------------------------
License Number | 26015162A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------