Provider Demographics
NPI:1407509524
Name:GIBSON, PATRICIA
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
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 1:90F GLENDA TRCE # 190
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3858
Mailing Address - Country:US
Mailing Address - Phone:678-541-7538
Mailing Address - Fax:678-692-6562
Practice Address - Street 1:59 TIFFANY TRACE
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:GA
Practice Address - Zip Code:30268
Practice Address - Country:US
Practice Address - Phone:678-541-7539
Practice Address - Fax:678-692-6562
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028836335251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health