Healthcare Provider Details

I. General information

NPI: 1780079889
Provider Name (Legal Business Name): REBECCA GIBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 W BAWKEY RD
FARWELL MI
48622-9207
US

IV. Provider business mailing address

4604 W BAWKEY RD
FARWELL MI
48622-9207
US

V. Phone/Fax

Practice location:
  • Phone: 989-621-4076
  • Fax:
Mailing address:
  • Phone: 989-621-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704198110
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: