Provider Demographics
NPI:1548822844
Name:GIBSON, HEIDI (NP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-9779
Mailing Address - Country:US
Mailing Address - Phone:810-721-7476
Mailing Address - Fax:810-721-7446
Practice Address - Street 1:1794 N LAPEER RD STE A
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-7664
Practice Address - Country:US
Practice Address - Phone:810-721-7476
Practice Address - Fax:810-721-7446
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily