1235444209 NPI number — LORI A GIBSON ARNP

Table of content: LORI A GIBSON ARNP (NPI 1235444209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235444209 NPI number — LORI A GIBSON ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235444209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 775985
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-5985
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-770-6900
Provider Business Mailing Address Fax Number:
317-770-6911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 NOBLE CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOBLESVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46060-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-773-8483
Provider Business Practice Location Address Fax Number:
317-776-0442
Provider Enumeration Date:
08/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  71003364A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201019130 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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