Provider Demographics
NPI:1710445754
Name:GIBBS, TANYA (FNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:GIBBS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 RAEFORD RD STE 6C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5098
Mailing Address - Country:US
Mailing Address - Phone:910-973-2689
Mailing Address - Fax:910-568-3908
Practice Address - Street 1:2529 RAEFORD RD STE 6C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5098
Practice Address - Country:US
Practice Address - Phone:910-973-2689
Practice Address - Fax:910-568-3908
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962494377Medicaid