Provider Demographics
NPI:1114743010
Name:GIBSON, SUSAN PHILLIPS (RPH, NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PHILLIPS
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RPH, NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 WINDERMERE AVE
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2314
Mailing Address - Country:US
Mailing Address - Phone:650-243-7135
Mailing Address - Fax:
Practice Address - Street 1:1004 WINDERMERE AVE
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2314
Practice Address - Country:US
Practice Address - Phone:650-243-7135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
IN26015162A1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No133N00000XDietary & Nutritional Service ProvidersNutritionist