Basic Information
Provider Information | |||||||||
NPI: | 1174524235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GIBBONS | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.R.N.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 567 | ||||||||
Address2: |   | ||||||||
City: | CHAGRIN FALLS | ||||||||
State: | OH | ||||||||
PostalCode: | 440220567 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2164645160 | ||||||||
FaxNumber: | 2164645982 | ||||||||
Practice Location | |||||||||
Address1: | 15345 BAGLEY RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441304825 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4407438400 | ||||||||
FaxNumber: | 4407438401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 166540 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0769440 | 05 | OH |   | MEDICAID |