Provider Demographics
NPI:1639772965
Name:GIBSON, ELIZABETH BROOK HANNAH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOK HANNAH
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:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:MAN
Mailing Address - State:WV
Mailing Address - Zip Code:25635-0225
Mailing Address - Country:US
Mailing Address - Phone:304-946-7519
Mailing Address - Fax:
Practice Address - Street 1:657 GREENVILLE RD
Practice Address - Street 2:
Practice Address - City:MAN
Practice Address - State:WV
Practice Address - Zip Code:25635
Practice Address - Country:US
Practice Address - Phone:304-946-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant