MEDICARE: MRS. MICHELLE BENDER GIBSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	0017137534	VA

General Provider Information

NPI Number	:	1124077136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE BENDER GIBSON NP

Provider Business Mailing Address
First Line	:	2232 WILBORN AVE, SUITE D
Second Line	:	HEMATOLOGY ONCOLOGY PRACTICE OF SOUTHSIDE VA, PC
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-1662
Country	:	US
Telephone Number	:	434-575-1212
Fax Number	:	434-575-1130

Provider Business Practice Location Address
First Line	:	2232 WILBORN AVE, SUITE D
Second Line	:	HEMATOLOGY ONCOLOGY PRACTICE OF SOUTHSIDE VA, PC
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-1662
Country	:	US
Telephone Number	:	434-575-1212
Fax Number	:	434-575-1130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	03/08/2010

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