Provider Demographics
NPI:1609321025
Name:GIBSON, LILLIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LILLIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PENDER DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-9312
Mailing Address - Country:US
Mailing Address - Phone:662-226-8900
Mailing Address - Fax:662-226-5767
Practice Address - Street 1:250 PENDER DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-9312
Practice Address - Country:US
Practice Address - Phone:662-226-8900
Practice Address - Fax:662-226-5767
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR704695163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool