Provider Demographics
NPI:1629564091
Name:GORMAN, KAIBAH
Entity Type:Individual
Prefix:
First Name:KAIBAH
Middle Name:
Last Name:GORMAN
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 1:807 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5527
Mailing Address - Country:US
Mailing Address - Phone:505-325-5358
Mailing Address - Fax:505-326-3085
Practice Address - Street 1:815 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5527
Practice Address - Country:US
Practice Address - Phone:505-325-5358
Practice Address - Fax:505-326-3085
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator