Provider Demographics
NPI:1174524235
Name:GIBBONS, KATHLEEN E (CRNA)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:E
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:15345 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4825
Practice Address - Country:US
Practice Address - Phone:440-743-8400
Practice Address - Fax:440-743-8401
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0769440Medicaid
OH0769440Medicaid