Basic Information
| Provider Information | |||||||||
| NPI: | 1235470840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNM, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 529 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814250529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703236141 | ||||||||
| FaxNumber: | 8552998071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 RIO GRANDE AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704973333 | ||||||||
| FaxNumber: | 8552997837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2013 | ||||||||
| LastUpdateDate: | 10/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN.0993153-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 367A00000X | 990644 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 16285832 | 05 | CO | MEDICAID | APN.0993153-NP | 01 | CO | STATE LICENSE | OTHER | 990644 | 01 | CO | STATE LICENSE | OTHER | 118859 | 01 | CO | STATE LICENSE | OTHER |