Provider Demographics
NPI:1508379116
Name:GIBSON, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46528 VALLEY CT APT 3019
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-1848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4327 4TH ST SE APT 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-3387
Practice Address - Country:US
Practice Address - Phone:434-480-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant