Healthcare Provider Details

I. General information

NPI: 1417602582
Provider Name (Legal Business Name): GIPSON MOBILE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W RUE DE LA BANQUE
SAINT LOUIS MO
63141-5134
US

IV. Provider business mailing address

1001 W RUE DE LA BANQUE
SAINT LOUIS MO
63141-5134
US

V. Phone/Fax

Practice location:
  • Phone: 714-366-3875
  • Fax:
Mailing address:
  • Phone: 714-366-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOANNE GIPSON
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 714-366-3875