Individual
MARY E GIBSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
APN
Contact information
Practice address
4749 LINCOLN MALL DR STE 204, MATTESON, IL 60443-3806
(708) 481-4200
(708) 481-3320
Mailing address
7804 W GOLF DR APT 2B, PALOS HEIGHTS, IL 60463-3067
(708) 481-4200
(708) 481-3302
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
209-000390
IL
363LA2200X
Adult Health Nurse Practitioner
Primary
209-000390
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01619268
BLUESHIELD NUMBER
IL
Enumeration date
06/05/2006
Last updated
11/15/2019
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