Provider Demographics
NPI:1386234805
Name:GIBSON, MELISSA CLAIRE (RD, LDN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:CLAIRE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:CLAIRE
Other - Last Name:ANIELAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:62 STONEBROOKE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-2468
Mailing Address - Country:US
Mailing Address - Phone:618-334-6235
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021001439133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric