Provider Demographics
NPI:1194396705
Name:GIBSON, CRYSTAL DAWN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:GIBSON
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 1:24 ANCHOR RD
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-9221
Mailing Address - Country:US
Mailing Address - Phone:304-583-7249
Mailing Address - Fax:
Practice Address - Street 1:24 ANCHOR RD
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635-9221
Practice Address - Country:US
Practice Address - Phone:304-583-7249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant