MEDICARE: ELIZABETH LAURA GIBBEMEYER 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	0024179602	VA

General Provider Information

NPI Number	:	1356968820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH LAURA GIBBEMEYER NP

Provider Business Mailing Address
First Line	:	4209 RIDGE TOP RD APT 410
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-1120
Country	:	US
Telephone Number	:	513-702-9430
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 JOSEPH SIEWICK DR STE 100
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-1737
Country	:	US
Telephone Number	:	571-665-6467
Fax Number	:

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

Provider Enumeration Date	:	07/01/2020
Last Update Date	:	03/28/2024

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