Provider Demographics
NPI:1154876423
Name:GIBSON, STACEY NICOLE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:NICOLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:STACEY
Other - Middle Name:NICOLE
Other - Last Name:TALBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD STE 147
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6755
Mailing Address - Country:US
Mailing Address - Phone:301-714-4350
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 147
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6755
Practice Address - Country:US
Practice Address - Phone:301-714-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily