Healthcare Provider Details

I. General information

NPI: 1912773979
Provider Name (Legal Business Name): HEATHER RENEE GIBSON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 ROXBURY RD
ROCKFORD IL
61107-5059
US

IV. Provider business mailing address

2205 S PERRYVILLE RD # 477
ROCKFORD IL
61108-8209
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-3000
  • Fax:
Mailing address:
  • Phone: 815-517-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028852
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041421874
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: