Provider Demographics
NPI:1851130702
Name:GIBB, MISTY DAWN (EMT, BI)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:GIBB
Suffix:
Gender:F
Credentials:EMT, BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 W 12TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3983
Mailing Address - Country:US
Mailing Address - Phone:310-987-1298
Mailing Address - Fax:
Practice Address - Street 1:943 W 12TH ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3983
Practice Address - Country:US
Practice Address - Phone:310-987-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE162320146N00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic