Provider Demographics
NPI:1407623937
Name:GIBSON, CRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7049
Mailing Address - Country:US
Mailing Address - Phone:564-219-0984
Mailing Address - Fax:
Practice Address - Street 1:5400 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7049
Practice Address - Country:US
Practice Address - Phone:564-219-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61100743164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse