Provider Demographics
NPI:1366598153
Name:GIBBONS BAKER, EMALIE JEAN (CNM)
Entity type:Individual
Prefix:MS
First Name:EMALIE
Middle Name:JEAN
Last Name:GIBBONS BAKER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12910 PINE LN
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-3263
Mailing Address - Country:US
Mailing Address - Phone:410-394-0126
Mailing Address - Fax:
Practice Address - Street 1:25500 POINT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:301-475-6250
Practice Address - Fax:301-475-6190
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR072551367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP34269Medicare UPIN