Provider Demographics
NPI:1609434828
Name:GIBSON, SHONDA
Entity Type:Individual
Prefix:
First Name:SHONDA
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 1:2166 CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1321
Mailing Address - Country:US
Mailing Address - Phone:513-307-7424
Mailing Address - Fax:
Practice Address - Street 1:2166 CRANE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1321
Practice Address - Country:US
Practice Address - Phone:513-307-7424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSD661078172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0205505Medicaid