Provider Demographics
NPI:1518721281
Name:GIBBS, SHANON T
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:T
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 1:1 E LEXINGTON AVE UNIT 1507
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-4202
Mailing Address - Country:US
Mailing Address - Phone:480-438-1399
Mailing Address - Fax:
Practice Address - Street 1:2364 CARVER AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409
Practice Address - Country:US
Practice Address - Phone:928-757-3989
Practice Address - Fax:928-692-0398
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12844C310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility