Provider Demographics
NPI:1467800573
Name:GIBSON, ODESSA ODARA (RN)
Entity Type:Individual
Prefix:MRS
First Name:ODESSA
Middle Name:ODARA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19454 NW 29TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-0600
Mailing Address - Country:US
Mailing Address - Phone:786-444-7655
Mailing Address - Fax:
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3302
Practice Address - Country:US
Practice Address - Phone:954-265-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9353890163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse