Healthcare Provider Details

I. General information

NPI: 1912854563
Provider Name (Legal Business Name): MISTI DAWN GIBSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2026
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E ELM AVE
SAN JON NM
88434-9724
US

IV. Provider business mailing address

1200 E ELM AVE
SAN JON NM
88434-9724
US

V. Phone/Fax

Practice location:
  • Phone: 575-403-7601
  • Fax:
Mailing address:
  • Phone: 575-403-7601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number88590
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: