Provider Demographics
NPI:1528035334
Name:GIBSON, SHIRELY (NP)
Entity Type:Individual
Prefix:
First Name:SHIRELY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 DOLLY PARTON PKWY
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-3961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 DOLLY PARTON PKWY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3961
Practice Address - Country:US
Practice Address - Phone:865-428-5614
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20235363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN595111Medicare UPIN
TN3346973Medicare ID - Type Unspecified