Provider Demographics
NPI:1235845298
Name:GIBSON, STEPHANIE RENAE (APN)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:RENAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6012 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4659
Mailing Address - Country:US
Mailing Address - Phone:856-325-6622
Mailing Address - Fax:
Practice Address - Street 1:6012 MAIN ST
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4659
Practice Address - Country:US
Practice Address - Phone:856-325-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR17445700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily