Provider Demographics
NPI:1043559628
Name:GIBSON, KELLY ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MULDOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6400 GREENFIELD RD
Mailing Address - Street 2:#908
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-9101
Mailing Address - Country:US
Mailing Address - Phone:410-796-5917
Mailing Address - Fax:
Practice Address - Street 1:6400 GREENFIELD RD
Practice Address - Street 2:#908
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-9101
Practice Address - Country:US
Practice Address - Phone:410-796-5917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-02
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR165752363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care