Provider Demographics
NPI:1912773979
Name:GIBSON, HEATHER RENEE (DNP)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RENEE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 S PERRYVILLE RD # 477
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-8209
Mailing Address - Country:US
Mailing Address - Phone:815-517-3630
Mailing Address - Fax:
Practice Address - Street 1:444 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5059
Practice Address - Country:US
Practice Address - Phone:815-398-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041421874163W00000X
IL209028852363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse