MEDICARE: MRS. DIANA L GIBBS RNC WHNP

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	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	072587	MO

General Provider Information

NPI Number	:	1912999251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANA L GIBBS RNC WHNP

Provider Business Mailing Address
First Line	:	400 SALISBURY ST
Second Line	:
City	:	MONTGOMERY CITY
State	:	MO
Zip	:	63361-1232
Country	:	US
Telephone Number	:	573-564-2495
Fax Number	:	573-564-5059

Provider Business Practice Location Address
First Line	:	400 SALISBURY ST
Second Line	:
City	:	MONTGOMERY CITY
State	:	MO
Zip	:	63361-1232
Country	:	US
Telephone Number	:	573-564-2495
Fax Number	:	573-564-5059

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	02/05/2010

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