Provider Demographics
NPI:1235894700
Name:GIBBONS, OLLIE RENEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:OLLIE
Middle Name:RENEE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:OLLIE
Other - Middle Name:RENEE
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:57 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2746
Mailing Address - Country:US
Mailing Address - Phone:606-528-9700
Mailing Address - Fax:606-528-8423
Practice Address - Street 1:57 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2746
Practice Address - Country:US
Practice Address - Phone:606-528-9700
Practice Address - Fax:606-528-8423
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016521363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3016521OtherFAMILY MEDICINE
KYF06212829Medicaid