Provider Demographics
NPI:1043567860
Name:GIBSON, TIFFANY (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
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 1:29 FOREST RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-4428
Mailing Address - Country:US
Mailing Address - Phone:845-290-1115
Mailing Address - Fax:
Practice Address - Street 1:29 FOREST RIDGE RD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-4428
Practice Address - Country:US
Practice Address - Phone:845-290-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303784-1164W00000X
FLPN5198425164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse