Provider Demographics
NPI:1497114789
Name:GIBSON, TERRIE
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WINROW AVE
Mailing Address - Street 2:USA MEDDAC, RWBACH
Mailing Address - City:FT. HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613
Mailing Address - Country:US
Mailing Address - Phone:520-533-5082
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:USA MEDDAC, RWBACH
Practice Address - City:FT. HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN085772163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN085772OtherRIGHT NOW LICENSE