Provider Demographics
NPI:1750656872
Name:GIBSON, HEATHER NICHOLE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICHOLE
Last Name:GIBSON
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 1:310 S APACHE
Mailing Address - Street 2:
Mailing Address - City:POND CREEK
Mailing Address - State:OK
Mailing Address - Zip Code:73766-9708
Mailing Address - Country:US
Mailing Address - Phone:580-532-5367
Mailing Address - Fax:
Practice Address - Street 1:1500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2827
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-2576
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator