Provider Demographics
NPI:1659568624
Name:GIBBLE, ROBERTA K (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:K
Last Name:GIBBLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LEO MOSS DR
Mailing Address - Street 2:SUITE 4308
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1100
Mailing Address - Country:US
Mailing Address - Phone:716-373-8040
Mailing Address - Fax:716-701-3279
Practice Address - Street 1:1 LEO MOSS DR
Practice Address - Street 2:SUITE 4308
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1100
Practice Address - Country:US
Practice Address - Phone:716-373-8040
Practice Address - Fax:716-701-3279
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510293-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00635098Medicaid