Provider Demographics
NPI:1821062241
Name:GIBEAULT, JEANANNE M (NP)
Entity Type:Individual
Prefix:
First Name:JEANANNE
Middle Name:M
Last Name:GIBEAULT
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:730 S CROUSE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1713
Mailing Address - Country:US
Mailing Address - Phone:315-234-6699
Mailing Address - Fax:315-234-4807
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1640
Practice Address - Country:US
Practice Address - Phone:315-234-6677
Practice Address - Fax:315-234-4808
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF3322891363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02056962Medicaid
NYDD5147Medicare ID - Type Unspecified
NY02056962Medicaid
NYDD5152Medicare ID - Type Unspecified