Provider Demographics
NPI:1306010632
Name:GIBSON, CHANTIA LEE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:CHANTIA
Middle Name:LEE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MRS
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:1909 HAMPSHIRE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5650
Mailing Address - Country:US
Mailing Address - Phone:931-388-5757
Mailing Address - Fax:
Practice Address - Street 1:1909 HAMPSHIRE PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5650
Practice Address - Country:US
Practice Address - Phone:931-388-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000204771163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse