Provider Demographics
NPI:1730524703
Name:GIBSON, LAUREN JOHNSON
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:JOHNSON
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:305 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3125
Mailing Address - Country:US
Mailing Address - Phone:931-372-2700
Mailing Address - Fax:
Practice Address - Street 1:305 W SPRING ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3125
Practice Address - Country:US
Practice Address - Phone:931-372-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-05
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10617390200000X
TN40381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty