MEDICARE: CORENA R GIBSON APRN

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	3003843	KY
2	363LF0000X	Family Nurse Practitioner	APN6725	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578546495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORENA R GIBSON APRN

Provider Business Mailing Address
First Line	:	PO BOX 1080
Second Line	:
City	:	BURKESVILLE
State	:	KY
Zip	:	42717-1080
Country	:	US
Telephone Number	:	270-864-1472
Fax Number	:	270-864-1472

Provider Business Practice Location Address
First Line	:	69 S MAIN ST
Second Line	:
City	:	WHITLEY CITY
State	:	KY
Zip	:	42653-6043
Country	:	US
Telephone Number	:	606-376-7399
Fax Number	:	606-376-7396

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

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	09/15/2014

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