Provider Demographics
NPI:1912999251
Name:GIBBS, DIANA L (RNC WHNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:L
Last Name:GIBBS
Suffix:
Gender:F
Credentials:RNC WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SALISBURY ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-1232
Mailing Address - Country:US
Mailing Address - Phone:573-564-2495
Mailing Address - Fax:573-564-5059
Practice Address - Street 1:400 SALISBURY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-1232
Practice Address - Country:US
Practice Address - Phone:573-564-2495
Practice Address - Fax:573-564-5059
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO072587363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPO5877Medicare UPIN
MO000080637Medicare ID - Type Unspecified