Provider Demographics
NPI:1942233762
Name:GIBSON, OLIVIA RUTH (RN/APRN)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:RUTH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RN/APRN
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:RUTH
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN/APRN
Mailing Address - Street 1:515 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5316
Mailing Address - Country:US
Mailing Address - Phone:912-283-5729
Mailing Address - Fax:912-490-5774
Practice Address - Street 1:515 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5316
Practice Address - Country:US
Practice Address - Phone:912-283-5729
Practice Address - Fax:912-490-5774
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113495363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000759536IMedicaid
GAS89375Medicare UPIN
GA50BBCZPMedicare ID - Type UnspecifiedBRANTLEY HD
GA50BBCZMMedicare ID - Type UnspecifiedCOFFEE HD
GA50BBHKSMedicare ID - Type UnspecifiedBACON HD
GA000759536IMedicaid