Healthcare Provider Details

I. General information

NPI: 1497114789
Provider Name (Legal Business Name): TERRIE GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 WINROW AVE USA MEDDAC, RWBACH
FT. HUACHUCA AZ
85613
US

IV. Provider business mailing address

2240 WINROW AVE USA MEDDAC, RWBACH
FT. HUACHUCA AZ
85613
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-5082
  • Fax:
Mailing address:
  • Phone: 520-533-5082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN085772
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: