Provider Demographics
NPI:1982475380
Name:GIBSON, KYRON JERREL SR
Entity Type:Individual
Prefix:
First Name:KYRON
Middle Name:JERREL
Last Name:GIBSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CARRABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:32322-5081
Mailing Address - Country:US
Mailing Address - Phone:850-323-2000
Mailing Address - Fax:
Practice Address - Street 1:1213 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:CARRABELLE
Practice Address - State:FL
Practice Address - Zip Code:32322-5081
Practice Address - Country:US
Practice Address - Phone:850-323-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL395756376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty