Provider Demographics
NPI:1639722572
Name:GIBSON-DOLFORD, MARCY (BUSINESS OWNER)
Entity Type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:
Last Name:GIBSON-DOLFORD
Suffix:
Gender:F
Credentials:BUSINESS OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30987 STONE RIDGE DR APT 1307
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-3896
Mailing Address - Country:US
Mailing Address - Phone:313-974-9257
Mailing Address - Fax:
Practice Address - Street 1:30987 STONE RIDGE DR APT 1307
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-3896
Practice Address - Country:US
Practice Address - Phone:313-974-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230015034740311376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty