Healthcare Provider Details

I. General information

NPI: 1285930818
Provider Name (Legal Business Name): MRS. SHELLY MARIE GIBBON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6116 ANNE MARIE CT
WEST BEND WI
53095-9167
US

IV. Provider business mailing address

6116 ANNE MARIE CT
WEST BEND WI
53095-9167
US

V. Phone/Fax

Practice location:
  • Phone: 262-629-5190
  • Fax:
Mailing address:
  • Phone: 262-629-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number132870-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number132870-30
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number132870-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: