Provider Demographics
NPI:1235338815
Name:GIBBONS, SANDRA L
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:L
Other - Last Name:SITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:120 MADISON STREET
Mailing Address - Street 2:PO BOX 581
Mailing Address - City:ORISKANY FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13425
Mailing Address - Country:US
Mailing Address - Phone:315-292-1623
Mailing Address - Fax:
Practice Address - Street 1:120 MADISON STREET
Practice Address - Street 2:
Practice Address - City:ORISKANY FALLS
Practice Address - State:NY
Practice Address - Zip Code:13425
Practice Address - Country:US
Practice Address - Phone:315-292-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251214164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01907955Medicaid