Provider Demographics
NPI:1619476082
Name:GIBSON, DIANA S
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:S
Other - Last Name:LORENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 KENSINGTON CIR APT B
Mailing Address - Street 2:
Mailing Address - City:GARNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10923-1629
Mailing Address - Country:US
Mailing Address - Phone:845-598-1633
Mailing Address - Fax:
Practice Address - Street 1:295 PHILLIPS HILL RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-2018
Practice Address - Country:US
Practice Address - Phone:845-598-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318869-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse