Provider Demographics
NPI:1003186347
Name:GIBSON, TANYA C (LPN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 FRONTIER TRL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2939
Mailing Address - Country:US
Mailing Address - Phone:419-544-1564
Mailing Address - Fax:
Practice Address - Street 1:1695 FRONTIER TRL
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2939
Practice Address - Country:US
Practice Address - Phone:419-544-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN097165-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse