Healthcare Provider Details

I. General information

NPI: 1861448227
Provider Name (Legal Business Name): KAREN L GIBBONS-BERRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 13TH ST SUITE 10
AUGUSTA GA
30901-2700
US

IV. Provider business mailing address

811 13TH ST SUITE 10
AUGUSTA GA
30901-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-1590
  • Fax: 803-279-6001
Mailing address:
  • Phone: 706-434-1590
  • Fax: 803-279-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202001584NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR093348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: