Provider Demographics
NPI:1902279110
Name:GIBBS WOUND CARE LLC
Entity Type:Organization
Organization Name:GIBBS WOUND CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:DEVONA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:573-686-4133
Mailing Address - Street 1:2210 BARRON RD
Mailing Address - Street 2:ROOM 205
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-4133
Mailing Address - Fax:573-778-1099
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:ROOM 205
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-4133
Practice Address - Fax:573-778-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0236239363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO064033OtherMISSOURI STATE BOARD OF NURSING
MO064033OtherMISSOURI STATE BOARD OF NURSING