Provider Demographics
NPI:1366480139
Name:GIBSON, NICOLE (DNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5009
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5009
Mailing Address - Country:US
Mailing Address - Phone:605-977-5000
Mailing Address - Fax:605-977-5377
Practice Address - Street 1:4520 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8148
Practice Address - Country:US
Practice Address - Phone:605-977-5000
Practice Address - Fax:605-977-5377
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000446363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-22224OtherMEDICA
SD4994462OtherSD BCBS
SD9237752OtherDAKOTACARE
MN435L7GIOtherMN BLUE SHIELD
SD6828020Medicaid
931451047321OtherPREFERRED ONE
01-22224OtherMEDICA
SD6828020Medicaid