Provider Demographics
NPI:1811190200
Name:GIBSON, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
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 1:6232 NIMITZ DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-2128
Mailing Address - Country:US
Mailing Address - Phone:317-353-2628
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:317-353-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN48010504492376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide