Provider Demographics
NPI:1417621798
Name:GIBBS, SAMANTHA KIA (LVN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KIA
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6637 SYLMAR AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-4798
Mailing Address - Country:US
Mailing Address - Phone:323-674-1507
Mailing Address - Fax:
Practice Address - Street 1:6637 SYLMAR AVE APT 201
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4798
Practice Address - Country:US
Practice Address - Phone:323-674-1507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA714443164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse