Provider Demographics
NPI:1457765315
Name:GIPSON, DACHIA
Entity Type:Individual
Prefix:
First Name:DACHIA
Middle Name:
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 ALCOY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-3313
Mailing Address - Country:US
Mailing Address - Phone:614-432-6747
Mailing Address - Fax:
Practice Address - Street 1:1789 ALCOY DR.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227
Practice Address - Country:US
Practice Address - Phone:614-432-6747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401646780514390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401646780514OtherSTNA