Provider Demographics
NPI:1275997686
Name:GIBSON, LESIA DARLENE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LESIA
Middle Name:DARLENE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9009
Mailing Address - Country:US
Mailing Address - Phone:304-933-3885
Mailing Address - Fax:
Practice Address - Street 1:527 MEDICAL PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9009
Practice Address - Country:US
Practice Address - Phone:304-933-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN81798364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health