MEDICARE: GIBBS FAMILY PRACTICE, LLC

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	363LF0000X	Family Nurse Practitioner	APN17718	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124450648	OTHER	TN	INDIVIDUAL NPI
2	1457726374	OTHER		GROUP TYPE II NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	3706725	OTHER	TN	MCPTAN

General Provider Information

NPI Number	:	1457726374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GIBBS FAMILY PRACTICE, LLC

Provider Business Mailing Address
First Line	:	7331 TAZEWELL PIKE
Second Line	:
City	:	CORRYTON
State	:	TN
Zip	:	37721-3516
Country	:	US
Telephone Number	:	865-249-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	7331 TAZEWELL PIKE
Second Line	:
City	:	CORRYTON
State	:	TN
Zip	:	37721-3516
Country	:	US
Telephone Number	:	865-249-8044
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MRS. LESLIE HEISER
Credential	:	FNP
Telephone Number	:	865-249-8044

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	05/23/2023

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Directions to “GIBBS FAMILY PRACTICE, LLC ” Practice Location

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