Provider Demographics
NPI:1134434772
Name:GIBSON, TINA FAYE (LPN)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:FAYE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:44865-1148
Mailing Address - Country:US
Mailing Address - Phone:567-224-9988
Mailing Address - Fax:
Practice Address - Street 1:63 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:OH
Practice Address - Zip Code:44865-1148
Practice Address - Country:US
Practice Address - Phone:567-224-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN108983-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse