Provider Demographics
NPI:1417764580
Name:GIBBS, STACEY R
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:GIBBS
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 1:3609 E NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-1645
Mailing Address - Country:US
Mailing Address - Phone:443-415-1409
Mailing Address - Fax:
Practice Address - Street 1:3609 E NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-1645
Practice Address - Country:US
Practice Address - Phone:443-415-1409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3570-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility