Healthcare Provider Details

I. General information

NPI: 1912000209
Provider Name (Legal Business Name): KATHLEEN ANN GIBSON RN, CNS, CWOCN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N. CALIFORNIA ST.
STOCKTON CA
95213-9008
US

IV. Provider business mailing address

3816 VERMEER DR
MODESTO CA
95356-2404
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-2000
  • Fax: 209-944-8374
Mailing address:
  • Phone: 209-526-5176
  • Fax: 209-944-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number1422
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number472301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: