Healthcare Provider Details

I. General information

NPI: 1861950362
Provider Name (Legal Business Name): LALOMIE TIBBS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CAROLINA ST
PHENIX CITY AL
36869-5435
US

IV. Provider business mailing address

5 CAROLINA ST
PHENIX CITY AL
36869-5435
US

V. Phone/Fax

Practice location:
  • Phone: 661-233-7803
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number212664
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: