MEDICARE: SHAWNA MARIE GIBBS LPN ADON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	043104570	IL

General Provider Information

NPI Number	:	1700543857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWNA MARIE GIBBS LPN ADON

Provider Business Mailing Address
First Line	:	3354 JEROME LN
Second Line	:
City	:	CAHOKIA HEIGHTS
State	:	IL
Zip	:	62206-2604
Country	:	US
Telephone Number	:	618-337-9400
Fax Number	:	618-337-9394

Provider Business Practice Location Address
First Line	:	3354 JEROME LN
Second Line	:
City	:	CAHOKIA HEIGHTS
State	:	IL
Zip	:	62206-2604
Country	:	US
Telephone Number	:	618-337-9400
Fax Number	:	618-337-9394

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2021
Last Update Date	:	01/27/2023

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