Provider Demographics
NPI:1023262615
Name:GIBSON, HOLLY MARIE (LMP)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MILO ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-4035
Mailing Address - Country:US
Mailing Address - Phone:360-301-0183
Mailing Address - Fax:
Practice Address - Street 1:310 HADLOCK BAY RD
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9721
Practice Address - Country:US
Practice Address - Phone:360-379-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-09
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60022015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist