Provider Demographics
NPI:1083126353
Name:CIPUS PIERRE, GERTHY
Entity Type:Individual
Prefix:
First Name:GERTHY
Middle Name:
Last Name:CIPUS PIERRE
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 1:200 OCEANGATE
Mailing Address - Street 2:STE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:847-852-0145
Mailing Address - Fax:
Practice Address - Street 1:1706 CLOVERDALE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5500
Practice Address - Country:US
Practice Address - Phone:618-482-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1014759363LF0000X
IL0192721363LF0000X
IL377001655363LP2300X
IL2023125387363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty