Healthcare Provider Details

I. General information

NPI: 1215915889
Provider Name (Legal Business Name): DEVONA J GIBBS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 TIMBER RIDGE TRL
POPLAR BLUFF MO
63901-1595
US

IV. Provider business mailing address

196 TIMBER RIDGE TRL ROOM 205
POPLAR BLUFF MO
63901-1595
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4133
  • Fax: 573-778-1099
Mailing address:
  • Phone: 573-778-2888
  • Fax: 877-610-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number064033
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: