Provider Demographics
NPI:1558990432
Name:GIBSON, LAWANDA D (PRACTICAL NURSE)
Entity Type:Individual
Prefix:MS
First Name:LAWANDA
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PRACTICAL NURSE
Other - Prefix:MS
Other - First Name:LAWANDA
Other - Middle Name:DASHAWN
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:19240 GAINSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1344
Mailing Address - Country:US
Mailing Address - Phone:313-564-9996
Mailing Address - Fax:
Practice Address - Street 1:21415 CIVIC CENTER DR STE 302
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3954
Practice Address - Country:US
Practice Address - Phone:484-202-7023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166730164W00000X
MI4703119637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG125488135293OtherMI STATE DRIVERS LICENSE