Provider Demographics
NPI:1689877649
Name:GIBSON-SCIPIO, WANDA MAREA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:MAREA
Last Name:GIBSON-SCIPIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:MAREA
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:6246 LINDSAY CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-2154
Mailing Address - Country:US
Mailing Address - Phone:248-894-6817
Mailing Address - Fax:
Practice Address - Street 1:20548 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1613
Practice Address - Country:US
Practice Address - Phone:313-255-3333
Practice Address - Fax:313-255-8679
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704123322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily