Healthcare Provider Details

I. General information

NPI: 1518426212
Provider Name (Legal Business Name): AUGUSTINA MARIE GIBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N SYLVAN DR
GREENVILLE NC
27834-5136
US

IV. Provider business mailing address

300 N SYLVAN DR
GREENVILLE NC
27834-5136
US

V. Phone/Fax

Practice location:
  • Phone: 252-917-9072
  • Fax:
Mailing address:
  • Phone: 252-917-9072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number25924228
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: