Provider Demographics
NPI:1689197519
Name:GIBSON, KIRK (MSN, RN, PCCN)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MSN, RN, PCCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4023
Mailing Address - Country:US
Mailing Address - Phone:318-840-4843
Mailing Address - Fax:
Practice Address - Street 1:919 WILLOW DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-4023
Practice Address - Country:US
Practice Address - Phone:318-840-4843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN136488163W00000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163W00000XNursing Service ProvidersRegistered Nurse