Healthcare Provider Details

I. General information

NPI: 1669306312
Provider Name (Legal Business Name): SHANELL GIBBONS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 OLD COUNTRY RD UNIT 108
RIVERHEAD NY
11901-4404
US

IV. Provider business mailing address

1661 OLD COUNTRY RD UNIT 108
RIVERHEAD NY
11901-4404
US

V. Phone/Fax

Practice location:
  • Phone: 347-743-5075
  • Fax:
Mailing address:
  • Phone: 347-743-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number593163
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: