Provider Demographics
NPI:1447647417
Name:GIPSON, KRISTINA NICOLE
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:NICOLE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 HWY 95A S.
Mailing Address - Street 2:STE C302
Mailing Address - City:FERNLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89408
Mailing Address - Country:US
Mailing Address - Phone:775-575-1818
Mailing Address - Fax:775-575-1808
Practice Address - Street 1:10775 DOUBLE R BLVD
Practice Address - Street 2:STE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521
Practice Address - Country:US
Practice Address - Phone:775-853-7475
Practice Address - Fax:775-853-2013
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505679Medicaid
NV100505679Medicaid