Provider Demographics
NPI:1104065267
Name:GIBSON, MELINDA FAYE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:FAYE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:MELINDA
Other - Middle Name:FAYE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:46 L V STABLER DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-3865
Mailing Address - Country:US
Mailing Address - Phone:334-382-9760
Mailing Address - Fax:334-383-9331
Practice Address - Street 1:300 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-2025
Practice Address - Country:US
Practice Address - Phone:334-382-2681
Practice Address - Fax:334-383-9884
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-069655363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51218738OtherBCBS ALABAMA
AL225930Medicaid
AL051048403OtherBLUE CROSS