Provider Demographics
NPI:1194512012
Name:GIBSON, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 SHORE CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1567
Mailing Address - Country:US
Mailing Address - Phone:248-508-2004
Mailing Address - Fax:800-925-7765
Practice Address - Street 1:1707 SHORE CLUB DR
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1567
Practice Address - Country:US
Practice Address - Phone:248-508-2004
Practice Address - Fax:800-925-7765
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No171400000XOther Service ProvidersHealth & Wellness Coach