MEDICARE: MRS. ODESSA ODARA GIBSON RN

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	163W00000X	Registered Nurse	RN9353890	FL

General Provider Information

NPI Number	:	1467800573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ODESSA ODARA GIBSON RN

Provider Business Mailing Address
First Line	:	19454 NW 29TH CT
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33056-0600
Country	:	US
Telephone Number	:	786-444-7655
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 JOHNSON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-3302
Country	:	US
Telephone Number	:	954-265-5808
Fax Number	:

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

Provider Enumeration Date	:	05/31/2016
Last Update Date	:	10/08/2020

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