Provider Demographics
NPI:1063888253
Name:GIBBONS, MICHAEL (CNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HIGH ST STE 213
Mailing Address - Street 2:
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-2679
Mailing Address - Country:US
Mailing Address - Phone:617-529-8170
Mailing Address - Fax:978-228-0126
Practice Address - Street 1:4 HIGH ST STE 213
Practice Address - Street 2:
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-2679
Practice Address - Country:US
Practice Address - Phone:617-529-8170
Practice Address - Fax:978-228-0126
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2264515363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health