Provider Demographics
NPI:1215771530
Name:GIBSON, LATRICE D
Entity type:Individual
Prefix:
First Name:LATRICE
Middle Name:D
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 1:276 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4727
Mailing Address - Country:US
Mailing Address - Phone:734-291-3240
Mailing Address - Fax:
Practice Address - Street 1:8714 MACARTHUR BLVD BLDG 13A
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3384
Practice Address - Country:US
Practice Address - Phone:734-291-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant