Provider Demographics
NPI:1548548928
Name:GIBSON, WALTER FRANK (LPN)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:FRANK
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 N ORANGE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2449
Mailing Address - Country:US
Mailing Address - Phone:407-926-4124
Mailing Address - Fax:407-926-4121
Practice Address - Street 1:37 N ORANGE AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-2449
Practice Address - Country:US
Practice Address - Phone:407-926-4124
Practice Address - Fax:407-926-4121
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL300562397253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003153000Medicaid