Provider Demographics
NPI:1285930818
Name:GIBBON, SHELLY MARIE
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:MARIE
Last Name:GIBBON
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 1:6116 ANNE MARIE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9167
Mailing Address - Country:US
Mailing Address - Phone:262-629-5190
Mailing Address - Fax:
Practice Address - Street 1:6116 ANNE MARIE CT
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9167
Practice Address - Country:US
Practice Address - Phone:262-629-5190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-29
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132870-30163WH1000X, 163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WH0200XNursing Service ProvidersRegistered NurseHome Health