Provider Demographics
NPI:1619741972
Name:GIBBS, KACEY
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:GIBBS
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:PO BOX 1484
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-1484
Mailing Address - Country:US
Mailing Address - Phone:502-222-2389
Mailing Address - Fax:
Practice Address - Street 1:4414 OLD LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:BUCKNER
Practice Address - State:KY
Practice Address - Zip Code:40010-9547
Practice Address - Country:US
Practice Address - Phone:502-222-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist