Healthcare Provider Details

I. General information

NPI: 1245712157
Provider Name (Legal Business Name): KALEB JOSEPH GIBBS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 RUIN CREEK RD
HENDERSON NC
27536-2927
US

IV. Provider business mailing address

359 TREMONT AVE
KENMORE NY
14217-2237
US

V. Phone/Fax

Practice location:
  • Phone: 252-438-4143
  • Fax:
Mailing address:
  • Phone: 716-485-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5010955
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343305
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: