Provider Demographics
NPI:1225633068
Name:GIBBS, JUSTINE ANNE (RN)
Entity Type:Individual
Prefix:MS
First Name:JUSTINE
Middle Name:ANNE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JUSTINE
Other - Middle Name:ANNE
Other - Last Name:HOAGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:400 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-882-9542
Mailing Address - Fax:607-274-6822
Practice Address - Street 1:400 LAKE STREET
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-882-9542
Practice Address - Fax:607-274-6822
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY583271163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse