Provider Demographics
NPI:1821783887
Name:GIBSON, KATHLEEN RAE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RAE
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 1:1496 W HOOSIER BLVD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-3727
Mailing Address - Country:US
Mailing Address - Phone:765-472-5032
Mailing Address - Fax:765-472-8999
Practice Address - Street 1:1496 W HOOSIER BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-3727
Practice Address - Country:US
Practice Address - Phone:765-472-5032
Practice Address - Fax:765-472-8999
Is Sole Proprietor?:No
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27056635A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse