Provider Demographics
NPI:1164483343
Name:GIBSON-DETERING, CARLA ANNETTE (FNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:ANNETTE
Last Name:GIBSON-DETERING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601409
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1409
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:201 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3917
Practice Address - Country:US
Practice Address - Phone:704-487-3798
Practice Address - Fax:704-487-3394
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2590923Medicare PIN
NCP20160Medicare UPIN