Provider Demographics
NPI:1902442221
Name:GIBSON, SHAUNA LATIECE
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:LATIECE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31624 N MARGINAL DR APT F
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-4422
Mailing Address - Country:US
Mailing Address - Phone:440-529-9931
Mailing Address - Fax:
Practice Address - Street 1:31624 N MARGINAL DR APT F
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4422
Practice Address - Country:US
Practice Address - Phone:440-529-9931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor