Provider Demographics
NPI:1417444274
Name:GIBSON, NIKELLE (LPN)
Entity Type:Individual
Prefix:MS
First Name:NIKELLE
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 1:4524 N CLAYHILL DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6847
Mailing Address - Country:US
Mailing Address - Phone:920-702-2125
Mailing Address - Fax:
Practice Address - Street 1:4524 N CLAYHILL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6847
Practice Address - Country:US
Practice Address - Phone:920-702-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI321215164W00000X
WI321215-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse