Provider Demographics
NPI:1194406694
Name:GIBSON, TYLER (RN)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 W BOWMAN ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2542
Mailing Address - Country:US
Mailing Address - Phone:765-729-6532
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95338777163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health