Provider Demographics
NPI:1457726374
Name:GIBBS FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:GIBBS FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:865-249-8044
Mailing Address - Street 1:7331 TAZEWELL PIKE
Mailing Address - Street 2:
Mailing Address - City:CORRYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37721-3516
Mailing Address - Country:US
Mailing Address - Phone:865-249-8044
Mailing Address - Fax:
Practice Address - Street 1:7331 TAZEWELL PIKE
Practice Address - Street 2:
Practice Address - City:CORRYTON
Practice Address - State:TN
Practice Address - Zip Code:37721-3516
Practice Address - Country:US
Practice Address - Phone:865-249-8044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN17718363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1124450648OtherINDIVIDUAL NPI
1457726374OtherGROUP TYPE II NPI
TN1532504Medicaid
TN3706725OtherMCPTAN
TN1532504Medicaid
TN10350I3869Medicare PIN