MEDICARE: LAURA GIBSON REGISTERED NURSE

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	164W00000X	Licensed Practical Nurse	327383	NY
2	163W00000X	Registered Nurse	741824	NY

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	:	1962939736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA GIBSON REGISTERED NURSE

Provider Business Mailing Address
First Line	:	2240 DR MARTIN L KING JR BLVD APT 6A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-1332
Country	:	US
Telephone Number	:	347-661-1306
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 UNIVERSITY AVE
Second Line	:	APT 6A
City	:	BRONX
State	:	NY
Zip	:	10453-1316
Country	:	US
Telephone Number	:	347-661-1306
Fax Number	:

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

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	01/17/2018

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