Provider Demographics
NPI:1497520043
Name:GIBBS, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ARLINGTON AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:THORNVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43076-3506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 ARLINGTON AVE APT 8
Practice Address - Street 2:
Practice Address - City:THORNVILLE
Practice Address - State:OH
Practice Address - Zip Code:43076-3506
Practice Address - Country:US
Practice Address - Phone:740-605-6732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61456239164X00000X
OHPN.159260164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse