Provider Demographics
NPI:1932951191
Name:GIBSON, ANTOINETTE LYNNE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:LYNNE
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 1:13010 CHESTNUT STREAM TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-1174
Mailing Address - Country:US
Mailing Address - Phone:210-724-3483
Mailing Address - Fax:
Practice Address - Street 1:5930 CORNERSTONE CT W
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3741
Practice Address - Country:US
Practice Address - Phone:866-687-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1139689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily