Provider Demographics
NPI:1427535889
Name:GIBBONS, MARY G (LM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:G
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19238 N 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5151
Mailing Address - Country:US
Mailing Address - Phone:623-451-4925
Mailing Address - Fax:
Practice Address - Street 1:3019 W MCRAE WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4915
Practice Address - Country:US
Practice Address - Phone:623-451-4925
Practice Address - Fax:623-451-4925
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0161176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife