Provider Demographics
NPI:1861709933
Name:GIBOO, AMY RAE (RN)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:RAE
Last Name:GIBOO
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 KING ST
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:NY
Mailing Address - Zip Code:14711-8682
Mailing Address - Country:US
Mailing Address - Phone:585-365-2646
Mailing Address - Fax:585-365-2648
Practice Address - Street 1:1 KING ST
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:NY
Practice Address - Zip Code:14711-8682
Practice Address - Country:US
Practice Address - Phone:585-365-2646
Practice Address - Fax:585-365-2648
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266865-1164W00000X
NY672036251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01377191Medicaid