Provider Demographics
NPI:1578546495
Name:GIBSON, CORENA R (APRN)
Entity Type:Individual
Prefix:
First Name:CORENA
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:APRN
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 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1472
Practice Address - Street 1:69 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-6043
Practice Address - Country:US
Practice Address - Phone:606-376-7399
Practice Address - Fax:606-376-7396
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003843363LF0000X
TNAPN6725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78009065Medicaid
KYK086450Medicare PIN
KYP75431Medicare UPIN
KY181882Medicare PIN
KY78009065Medicaid