Provider Demographics
NPI:1467625632
Name:GIBSON, LISA CAMILLE (RN BSN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CAMILLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 NE 162ND AVE
Mailing Address - Street 2:ALBERTINA KERR CENTER YOUTH & FAMILY SERVICES
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97024
Mailing Address - Country:US
Mailing Address - Phone:503-255-4205
Mailing Address - Fax:
Practice Address - Street 1:722 NE 162ND AVE
Practice Address - Street 2:ALBERTINA KERR CENTER YOUTH & FAMILY SERVICES
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97024
Practice Address - Country:US
Practice Address - Phone:503-255-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health