Basic Information
| Provider Information | |||||||||
| NPI: | 1912000209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RN, CNS, CWOCN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3816 VERMEER DR | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953562404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095265176 | ||||||||
| FaxNumber: | 2099448374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 N. CALIFORNIA ST. | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952139008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099432000 | ||||||||
| FaxNumber: | 2099448374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 163WE0900X | 472301 | CA | X | Nursing Service Providers | Registered Nurse | Enterostomal Therapy | 364S00000X | 1422 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.