Basic Information
| Provider Information | |||||||||
| NPI: | 1215915889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | DEVONA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 TIMBER RIDGE TRL | ||||||||
| Address2: | ROOM 205 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737782888 | ||||||||
| FaxNumber: | 8776103774 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 TIMBER RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864133 | ||||||||
| FaxNumber: | 5737781099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 064033 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 428182034 | 05 | MO | MEDICAID | 133802758 | 05 | AR | MEDICAID | 500000980 | 01 | TRAVELERS MEDICARE | OTHER |