Healthcare Provider Details

I. General information

NPI: 1851201578
Provider Name (Legal Business Name): EMMALYN GRACE GIBSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 N CAMPUS
ITHACA NY
14853-6007
US

IV. Provider business mailing address

7122 STAGECOACH RD
CONESUS NY
14435-9640
US

V. Phone/Fax

Practice location:
  • Phone: 607-255-4237
  • Fax:
Mailing address:
  • Phone: 585-208-9161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number005124-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: