Provider Demographics
NPI:1386404630
Name:GIBSON, KOURTNEY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 WARREN MASON BLVD UNIT 702
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1333
Mailing Address - Country:US
Mailing Address - Phone:912-324-1651
Mailing Address - Fax:
Practice Address - Street 1:3441 CYPRESS MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2879
Practice Address - Country:US
Practice Address - Phone:912-275-4763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN273930163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse