Provider Demographics
NPI:1730720699
Name:GIBBONS, MARY KAY A (RN)
Entity type:Individual
Prefix:MISS
First Name:MARY KAY
Middle Name:A
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BEACH 105 STREET
Mailing Address - Street 2:12F
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694
Mailing Address - Country:US
Mailing Address - Phone:718-318-8454
Mailing Address - Fax:
Practice Address - Street 1:1 BEACH 105 STREET
Practice Address - Street 2:12F
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694
Practice Address - Country:US
Practice Address - Phone:718-318-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY662160163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health