Provider Demographics
NPI:1619307964
Name:GIBSON, LEOTA LYNN
Entity Type:Individual
Prefix:
First Name:LEOTA
Middle Name:LYNN
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 1:4642 S 282ND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-1110
Mailing Address - Country:US
Mailing Address - Phone:206-818-9863
Mailing Address - Fax:
Practice Address - Street 1:4642 S 282ND ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-1110
Practice Address - Country:US
Practice Address - Phone:206-818-9863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 00002387314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility