Provider Demographics
NPI:1124184460
Name:GIBBONS, LINDSAY R (NP)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:R
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:R
Other - Last Name:HOURTIENNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 150036
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-0036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:743 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6045
Practice Address - Country:US
Practice Address - Phone:616-456-9553
Practice Address - Fax:616-454-5371
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704234804363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5008771990OtherBLUE CROSS BLUE SHIELD PIN
MI1124184460OtherTRICARE NPI
MN5008771990OtherBLUE CROSS BLUE SHIELD PIN