Provider Demographics
NPI:1699410324
Name:GIBSON, LYDIA (CRNP)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E OLNEY AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2470
Mailing Address - Country:US
Mailing Address - Phone:215-456-1825
Mailing Address - Fax:215-456-5926
Practice Address - Street 1:609 W GERMANTOWN PIKE STE 260
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-4243
Practice Address - Country:US
Practice Address - Phone:484-622-7820
Practice Address - Fax:484-622-7830
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1040204430004Medicaid