Provider Demographics
NPI:1336697846
Name:GIBBS, SHELLI
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:
Last Name:GIBBS
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 1:267 TREELAND DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:267 TREELAND DR
Practice Address - Street 2:SUITE C
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-3083
Practice Address - Country:US
Practice Address - Phone:843-277-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20314363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily