Provider Demographics
NPI:1790428357
Name:GIBBS, DEONTE ALONZO I (MN-CNL, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DEONTE
Middle Name:ALONZO
Last Name:GIBBS
Suffix:I
Gender:M
Credentials:MN-CNL, PMHNP-BC
Other - Prefix:MR
Other - First Name:DEONTE
Other - Middle Name:ALONZO
Other - Last Name:GIBBS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:DEONTE GIBBS
Mailing Address - Street 1:11221 SYNERGY DR APT 384
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1287
Mailing Address - Country:US
Mailing Address - Phone:262-328-7925
Mailing Address - Fax:
Practice Address - Street 1:2428 N GRANDVIEW BLVD STE 102
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6906
Practice Address - Country:US
Practice Address - Phone:262-875-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI239054-30163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty