MEDICARE: AMY M. GANNON RDLD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	438	WV

General Provider Information

NPI Number	:	1962743773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY M. GANNON RDLD

Provider Business Mailing Address
First Line	:	1 JOHN MARSHALL DR
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25755-0003
Country	:	US
Telephone Number	:	304-696-4336
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 JOHN MARSHALL DR
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25755-0003
Country	:	US
Telephone Number	:	304-696-4336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2013
Last Update Date	:	09/01/2020

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