Provider Demographics
NPI:1477833648
Name:GIBSON, CAROL LACY (FNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LACY
Last Name:GIBSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LACY
Other - Last Name:VOIVODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1452 CHAIN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3706
Mailing Address - Country:US
Mailing Address - Phone:571-239-2765
Mailing Address - Fax:
Practice Address - Street 1:1452 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:571-239-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164967363LF0000X
DCRN62762363LF0000X
MDR154036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily