Provider Demographics
NPI:1104563626
Name:GIBSON, MALYNDA (FNP-C)
Entity type:Individual
Prefix:
First Name:MALYNDA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 E UNION VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865-4423
Mailing Address - Country:US
Mailing Address - Phone:865-201-3062
Mailing Address - Fax:
Practice Address - Street 1:740 MIDDLE CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5056
Practice Address - Country:US
Practice Address - Phone:865-453-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ079053Medicaid