Provider Demographics
NPI:1326805250
Name:GIBSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 HIGHWAY 154
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:63382-3110
Mailing Address - Country:US
Mailing Address - Phone:217-313-5921
Mailing Address - Fax:
Practice Address - Street 1:2207 HIGHWAY 154
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382-3110
Practice Address - Country:US
Practice Address - Phone:217-313-5921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach