Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 064033 | MO |
NPI | 1215915889 |
---|---|
Provider Name | Devona J Gibbs |
First Address | Poplar Bluff, MO 63901-1595 |
Second Address | Poplar Bluff, MO 63901-1595 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2006 |
Last Update Date | 25/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
133802758 | (05) | AR |
428182034 | (05) | MO |
500000980 | TRAVELERS MEDICARE (01) | |
S06965 | (02) | MO |