Provider Demographics
NPI:1073035895
Name:GIBBONS, PORIRTIA JEANETTE
Entity Type:Individual
Prefix:MRS
First Name:PORIRTIA
Middle Name:JEANETTE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 PUBLIC LANDING RD
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21863-2453
Mailing Address - Country:US
Mailing Address - Phone:410-632-1100
Mailing Address - Fax:410-632-5682
Practice Address - Street 1:424 W MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863-1268
Practice Address - Country:US
Practice Address - Phone:410-632-9230
Practice Address - Fax:410-632-9239
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator