Provider Demographics
NPI:1225279946
Name:GIBSON, TRACEY (RNFA)
Entity Type:Individual
Prefix:MISS
First Name:TRACEY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-878-7150
Mailing Address - Fax:314-878-3051
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-878-7150
Practice Address - Fax:314-878-3051
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123572163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant