Provider Demographics
NPI:1962939736
Name:GIBSON, LAURA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2240 DR MARTIN L KING JR BLVD APT 6A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-1332
Mailing Address - Country:US
Mailing Address - Phone:347-661-1306
Mailing Address - Fax:
Practice Address - Street 1:2240 UNIVERSITY AVE
Practice Address - Street 2:APT 6A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-1316
Practice Address - Country:US
Practice Address - Phone:347-661-1306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327383164W00000X
NY741824163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY327383Medicaid