Provider Demographics
NPI:1316597297
Name:GIBBS, KERRY (ANP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HICKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3443
Mailing Address - Country:US
Mailing Address - Phone:516-717-1839
Mailing Address - Fax:
Practice Address - Street 1:1371 SEABURY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-294-6200
Practice Address - Fax:718-294-6259
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251826363LA2200X
NYF309445363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty