Provider Demographics
NPI:1417745738
Name:GIBBONS, SHELLEY (RN)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 COUNTY ROUTE 51 BLDG 1
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-4502
Mailing Address - Country:US
Mailing Address - Phone:518-483-1251
Mailing Address - Fax:
Practice Address - Street 1:31 6TH ST # A
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1246
Practice Address - Country:US
Practice Address - Phone:518-483-3261
Practice Address - Fax:518-483-3383
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY406717163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse