Provider Demographics
NPI:1093294282
Name:GIBSON, AMANDA M (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8923
Mailing Address - Fax:765-935-8407
Practice Address - Street 1:1050 REID PKWY STE 110
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-935-8923
Practice Address - Fax:765-935-8407
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008184A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71008184AOtherFAMILY NURSE PRACTITIONER