Provider Demographics
NPI:1124712997
Name:GIBSON, LATOYA SHAWNTEE
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:SHAWNTEE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 N 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5964
Mailing Address - Country:US
Mailing Address - Phone:318-884-7347
Mailing Address - Fax:
Practice Address - Street 1:809 N 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5964
Practice Address - Country:US
Practice Address - Phone:318-884-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver