Provider Demographics
NPI:1689942278
Name:GIPSON, STEPHANIE NATASHA (LPN)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:NATASHA
Last Name:GIPSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4245 FOREST PARK AVE
Mailing Address - Street 2:ATTN: MWP-ACCOUNTING DEPT
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2810
Mailing Address - Country:US
Mailing Address - Phone:314-286-4545
Mailing Address - Fax:314-286-4542
Practice Address - Street 1:4219 LACLEDE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2814
Practice Address - Country:US
Practice Address - Phone:314-286-4545
Practice Address - Fax:314-286-4542
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008035985164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse