Provider Demographics
NPI:1699244400
Name:GIBBS, JAEVONNA ANGELIQUE
Entity type:Individual
Prefix:
First Name:JAEVONNA
Middle Name:ANGELIQUE
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 1:13 RIO GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-9761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13 RIO GRANDE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-9761
Practice Address - Country:US
Practice Address - Phone:585-414-0964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333815164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse