Provider Demographics
NPI:1689314221
Name:GIBBONS, EILEEN FARRELL
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:FARRELL
Last Name:GIBBONS
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 1:82 N HOWELLS POINT RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2313
Mailing Address - Country:US
Mailing Address - Phone:631-807-9111
Mailing Address - Fax:
Practice Address - Street 1:235 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1261
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY950373171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor