Provider Demographics
NPI:1063301133
Name:GIBSON, TELIAH RAE (LPN, CBS)
Entity type:Individual
Prefix:MS
First Name:TELIAH
Middle Name:RAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPN, CBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 PINE RIDGE RD N
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18302-8673
Mailing Address - Country:US
Mailing Address - Phone:570-369-2849
Mailing Address - Fax:
Practice Address - Street 1:500 PLAZA CT STE A
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-8262
Practice Address - Country:US
Practice Address - Phone:570-476-3585
Practice Address - Fax:570-421-9014
Is Sole Proprietor?:No
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA174400000X, 174N00000X
PA310699164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No174400000XOther Service ProvidersSpecialist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN