Healthcare Provider Details

I. General information

NPI: 1245062827
Provider Name (Legal Business Name): ALICE FAY GIBSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 NEELY RD
FT WAINWRIGHT AK
99703-7400
US

IV. Provider business mailing address

PO BOX 70715
FAIRBANKS AK
99707-0715
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-5656
  • Fax:
Mailing address:
  • Phone: 907-529-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number8116
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: