Provider Demographics
NPI:1447863337
Name:GIBSON, JUDITH (MSOM, DIPL ACU, LAC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSOM, DIPL ACU, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 DEER WOOD TRL
Mailing Address - Street 2:
Mailing Address - City:PEGRAM
Mailing Address - State:TN
Mailing Address - Zip Code:37143-5061
Mailing Address - Country:US
Mailing Address - Phone:608-235-8138
Mailing Address - Fax:
Practice Address - Street 1:3808 PARK AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-3741
Practice Address - Country:US
Practice Address - Phone:615-499-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN173171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty