Provider Demographics
NPI:1689405953
Name:GIBSON, GRACIE NOEL I
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:NOEL
Last Name:GIBSON
Suffix:I
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 1:11385 S OLD BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IN
Mailing Address - Zip Code:47165-8622
Mailing Address - Country:US
Mailing Address - Phone:812-987-6459
Mailing Address - Fax:
Practice Address - Street 1:2100 GARDINER LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2962
Practice Address - Country:US
Practice Address - Phone:502-413-8640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45023393A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program