Healthcare Provider Details

I. General information

NPI: 1881103042
Provider Name (Legal Business Name): STANLEY OWEN GIBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SPALDING DR
NAPERVILLE IL
60540-6550
US

IV. Provider business mailing address

4837 KINGSTON AVE
LISLE IL
60532-2220
US

V. Phone/Fax

Practice location:
  • Phone: 708-790-1872
  • Fax:
Mailing address:
  • Phone: 630-347-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016153
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.398583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: