Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | C893 | ID |
NPI | 1073676607 |
---|---|
Provider Name | Dr. Terri L Gibbs |
First Address | Boise, ID 83703-4827 |
Second Address | Boise, ID 83702-2202 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010022602 | REGENCE B SHIELD (01) | ID |
C6665 | BLUE CROSS (01) | ID |