Provider Demographics
NPI:1407842123
Name:GIBILTERRA, STACEY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:GIBILTERRA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21216 NORTHWEST FWY
Mailing Address - Street 2:STE. 460
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-1439
Mailing Address - Country:US
Mailing Address - Phone:281-807-5300
Mailing Address - Fax:281-807-5311
Practice Address - Street 1:21216 NORTHWEST FWY
Practice Address - Street 2:STE. 460
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-1439
Practice Address - Country:US
Practice Address - Phone:281-807-5300
Practice Address - Fax:281-807-5311
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX727283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1432083Medicaid
LA1432083Medicaid