Basic Information
| Provider Information | |||||||||
| NPI: | 1316360159 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIPSON | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 2ND AVE | ||||||||
| Address2: | SUITE C6 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707457246 | ||||||||
| FaxNumber: | 2702822027 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 2ND AVE | ||||||||
| Address2: | SUITE C6 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707457246 | ||||||||
| FaxNumber: | 2702822027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3008501 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 1126335 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100281220 | 05 | KY | MEDICAID |