Provider Demographics
NPI:1689031882
Name:GIBBENS, LEILANI
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:
Last Name:GIBBENS
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 1:105 ROYALTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-7025
Mailing Address - Country:US
Mailing Address - Phone:318-201-0258
Mailing Address - Fax:
Practice Address - Street 1:401 AUDUBON BLVD
Practice Address - Street 2:SUITE 102B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2676
Practice Address - Country:US
Practice Address - Phone:337-237-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily