Provider Demographics
NPI:1659753259
Name:GIBSON, ANNMARIE LUCILLE (NP-C)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:LUCILLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ANNMARIE
Other - Middle Name:L
Other - Last Name:GUARDIOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4386 MIDDLEDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1160
Mailing Address - Country:US
Mailing Address - Phone:248-420-1247
Mailing Address - Fax:
Practice Address - Street 1:4386 MIDDLEDALE AVE
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-1160
Practice Address - Country:US
Practice Address - Phone:248-420-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202970163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1659753259Medicaid
MIMI5868002Medicare PIN