Provider Demographics
NPI:1770020414
Name:KNIFFIN, GARY (LPN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:KNIFFIN
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GUACHPANGUE RD
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3424
Mailing Address - Country:US
Mailing Address - Phone:505-747-8187
Mailing Address - Fax:
Practice Address - Street 1:208 GUACHPANGUE RD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3424
Practice Address - Country:US
Practice Address - Phone:505-747-8187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPN22494164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse