Provider Demographics
NPI:1770210718
Name:GIBSON, ANITA LASHERYL
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:LASHERYL
Last Name:GIBSON
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 1:108 BANKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5039
Mailing Address - Country:US
Mailing Address - Phone:314-456-9566
Mailing Address - Fax:601-790-9759
Practice Address - Street 1:108 BANKSIDE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5039
Practice Address - Country:US
Practice Address - Phone:314-456-9566
Practice Address - Fax:601-790-9759
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications