Provider Demographics
NPI:1861448227
Name:GIBBONS-BERRY, KAREN L (FNP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:GIBBONS-BERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 13TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2700
Mailing Address - Country:US
Mailing Address - Phone:706-434-1590
Mailing Address - Fax:803-279-6001
Practice Address - Street 1:811 13TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2700
Practice Address - Country:US
Practice Address - Phone:706-434-1590
Practice Address - Fax:803-279-6001
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202001584NP-PP363LF0000X
GAR093348363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ19723Medicare UPIN
GA50BBHMWMedicare PIN
GA50BBHMWMedicare ID - Type UnspecifiedMEDICARE PROVIDER #