Provider Demographics
NPI:1578143624
Name:GIBSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5963 HANNAN TRACE RD
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25520-9080
Mailing Address - Country:US
Mailing Address - Phone:304-593-4922
Mailing Address - Fax:
Practice Address - Street 1:5963 HANNAN TRACE RD
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:WV
Practice Address - Zip Code:25520-9080
Practice Address - Country:US
Practice Address - Phone:304-593-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker