Healthcare Provider Details

I. General information

NPI: 1083126353
Provider Name (Legal Business Name): GERTHY CIPUS PIERRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 CLOVERDALE DR
EDWARDSVILLE IL
62025-5500
US

IV. Provider business mailing address

200 OCEANGATE STE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 618-482-6959
  • Fax:
Mailing address:
  • Phone: 847-852-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1014759
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0192721
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number377001655
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023125387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: