Provider Demographics
NPI:1558784975
Name:GIBBS, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GIBBS
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:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:WEARE
Mailing Address - State:NH
Mailing Address - Zip Code:03281-0228
Mailing Address - Country:US
Mailing Address - Phone:601-681-4985
Mailing Address - Fax:603-529-5981
Practice Address - Street 1:1102 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4001
Practice Address - Country:US
Practice Address - Phone:601-703-5600
Practice Address - Fax:601-703-5690
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily