Provider Demographics
NPI:1225403983
Name:GIBSON, ROSIE P
Entity Type:Individual
Prefix:MS
First Name:ROSIE
Middle Name:P
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 1:1536 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1482
Mailing Address - Country:US
Mailing Address - Phone:386-559-4005
Mailing Address - Fax:
Practice Address - Street 1:1536 MISSISSIPPI ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1482
Practice Address - Country:US
Practice Address - Phone:386-559-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-07
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X, 172V00000X, 172V00000X
FLCNA96647376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's Aide