Healthcare Provider Details

I. General information

NPI: 1902279110
Provider Name (Legal Business Name): GIBBS WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 BARRON RD ROOM 205
POPLAR BLUFF MO
63901-1908
US

IV. Provider business mailing address

2210 BARRON RD ROOM 205
POPLAR BLUFF MO
63901-1908
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-4133
  • Fax: 573-778-1099
Mailing address:
  • Phone: 573-686-4133
  • Fax: 573-778-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number0236239
License Number StateMO

VIII. Authorized Official

Name: DEVONA D GIBBS
Title or Position: NURSE PRACTITIONER
Credential: FNP
Phone: 573-686-4133