Basic Information
| Provider Information | |||||||||
| NPI: | 1538701917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | WHITTANY | ||||||||
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| Credential: | RDN, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S GULPH RD | ||||||||
| Address2: | ATTN: IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103824943 | ||||||||
| FaxNumber: | 6108783965 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 MANATEE AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412544957 | ||||||||
| FaxNumber: | 9412544958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2019 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 9493 | FL | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1201X | 9493 | FL | Y | 133N00000X | 9493 | FL | N | Dietary & Nutritional Service Providers | Nutritionist | 133NN1002X | 9493 | FL | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.