Healthcare Provider Details

I. General information

NPI: 1881531499
Provider Name (Legal Business Name): GIBSON WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 US HWY 319 S, MOULTRIE, GA 31768, MOULTRIE, GA 3176 UNIT 12
MOULTRIE GA
31768
US

IV. Provider business mailing address

143 US HWY 319 S, MOULTRIE, GA 31768, MOULTRIE, GA 3176 UNIT 12
MOULTRIE GA
31768
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-0208
  • Fax:
Mailing address:
  • Phone: 229-985-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIFFANIE A GIBSON
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 229-985-0208