Provider Demographics
NPI:1578852596
Name:GIBEAUT, CASSONDRA LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CASSONDRA
Middle Name:LYNN
Last Name:GIBEAUT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-5737
Mailing Address - Country:US
Mailing Address - Phone:541-990-5039
Mailing Address - Fax:
Practice Address - Street 1:5860 NW HIGHLAND PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-9729
Practice Address - Country:US
Practice Address - Phone:541-745-5799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130082LPN164W00000X
OR200412048CNA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide