Starr'Retiece R Gibson, LICENSED DIETITIAN
Individual provider Active NPI Registered Dietitian · Sauget, IL
NPI 1033934641 · NPPES record last updated Nov 19, 2024
Key facts
- NPI
- 1033934641
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Dietitian 133V00000X
- License
- 164.008825 (IL)
- Practice address
- 2071 Goose Lake Rd
Sauget, IL 62206-2822 - Phone
- (618) 857-2700
- NPI assigned
- Nov 19, 2024
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 164.008825 | IL | MD | Registered Dietitian |
Interoperability endpoints
- star.retiece.gibson.1@9559.direct.athenahealth.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 164.008825 | IL | Yes |
Addresses
Primary practice location
2071 Goose Lake Rd
Sauget, IL 62206-2822
Mailing address
2041 Goose Lake Rd
Sauget, IL 62206-2822
Phone (618) 332-0953
Other providers in Sauget, IL
- Best Foot Forward Corp
- Samantha Fisher
- Pillpack LLC
- R&R 1 LLC
- Renal Treatment Centers-Illinois Inc
- Michael Riley Jr.
- Southern Illinois Health Care Foundation, Inc.
All providers in Sauget, IL · Registered Dietitian in Illinois
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 19, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.