Healthcare Provider Details

I. General information

NPI: 1457726374
Provider Name (Legal Business Name): GIBBS FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7331 TAZEWELL PIKE
CORRYTON TN
37721-3516
US

IV. Provider business mailing address

7331 TAZEWELL PIKE
CORRYTON TN
37721-3516
US

V. Phone/Fax

Practice location:
  • Phone: 865-249-8044
  • Fax:
Mailing address:
  • Phone: 865-249-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN17718
License Number StateTN

VIII. Authorized Official

Name: MRS. LESLIE HEISER
Title or Position: SOLE MEMBER
Credential: FNP
Phone: 865-249-8044