Provider Demographics
NPI:1255638706
Name:GIBSON, HEIDI MARIE (LVN)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13654 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6706
Mailing Address - Country:US
Mailing Address - Phone:909-478-4683
Mailing Address - Fax:
Practice Address - Street 1:13654 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-6706
Practice Address - Country:US
Practice Address - Phone:909-478-4683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190050164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse