Provider Demographics
NPI:1356806129
Name:GIBSON, AUGUSTINA DORA
Entity type:Individual
Prefix:MRS
First Name:AUGUSTINA
Middle Name:DORA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AUGUSTINA
Other - Middle Name:DORA
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5155 SCOFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3301
Mailing Address - Country:US
Mailing Address - Phone:470-326-0286
Mailing Address - Fax:404-559-8804
Practice Address - Street 1:5155 SCOFIELD RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-3301
Practice Address - Country:US
Practice Address - Phone:470-326-0286
Practice Address - Fax:404-559-8804
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver