Provider Demographics
NPI:1912552324
Name:GIBSON, KIMBERLY LYNN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 NW 21ST CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3214
Mailing Address - Country:US
Mailing Address - Phone:513-780-3843
Mailing Address - Fax:
Practice Address - Street 1:3030 NW 21ST CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-3214
Practice Address - Country:US
Practice Address - Phone:513-780-3843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-03
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400328810204376K00000X
FL1092422106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123023500Medicaid
OH0330858Medicaid