Provider Demographics
NPI:1124211073
Name:GIBBS, KELLEY I (NP)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:I
Last Name:GIBBS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:I
Other - Last Name:GIBBS-BUDD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6085 HEARTLAND DR STE 205
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-4433
Practice Address - Country:US
Practice Address - Phone:317-768-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000761A363LP2300X
IN28123190A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200410950Medicaid