Provider Demographics
NPI:1184011942
Name:GIPSON, KIARA
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:
Last Name:GIPSON
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:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0284
Mailing Address - Country:US
Mailing Address - Phone:678-595-7010
Mailing Address - Fax:
Practice Address - Street 1:1200 W MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE INSTITUTE
Practice Address - State:AL
Practice Address - Zip Code:36088-1923
Practice Address - Country:US
Practice Address - Phone:678-595-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0023752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer