Provider Demographics
NPI:1285005454
Name:GIBBS, LYNNE (DC)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 CLARKSON EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2176
Mailing Address - Country:US
Mailing Address - Phone:636-628-7909
Mailing Address - Fax:
Practice Address - Street 1:485 WILDWOOD PKWY STE 4
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2667
Practice Address - Country:US
Practice Address - Phone:636-345-5100
Practice Address - Fax:636-216-0346
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026851111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA271103Medicare PIN