MEDICARE: MRS. ALICIA A. GIBBS 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	163WS0200X	School Registered Nurse	RN37208	SC

General Provider Information

NPI Number	:	1629415831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICIA A. GIBBS RN

Provider Business Mailing Address
First Line	:	735 PINE RIDGE DR
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29172-1831
Country	:	US
Telephone Number	:	803-755-7409
Fax Number	:	803-755-7449

Provider Business Practice Location Address
First Line	:	735 PINE RIDGE DR
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29172-1831
Country	:	US
Telephone Number	:	803-755-7409
Fax Number	:	803-755-7449

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

Provider Enumeration Date	:	05/29/2013
Last Update Date	:	05/29/2013

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