Healthcare Provider Details

I. General information

NPI: 1194662767
Provider Name (Legal Business Name): KATIE BETH GIBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARKWAY LN STE 100
PETAL MS
39465-3059
US

IV. Provider business mailing address

46 CARRIAGE PARKE DR
PURVIS MS
39475-6052
US

V. Phone/Fax

Practice location:
  • Phone: 601-705-2897
  • Fax:
Mailing address:
  • Phone: 662-825-4731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908429
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number908429
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: