Healthcare Provider Details

I. General information

NPI: 1972847374
Provider Name (Legal Business Name): LAUREL SUSAN KIBLER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W SCOTT ST
WILLCOX AZ
85643-1017
US

IV. Provider business mailing address

901 WEST REX ALLEN DRIVE
WILLCOX AZ
85643
US

V. Phone/Fax

Practice location:
  • Phone: 520-384-4421
  • Fax: 520-384-4645
Mailing address:
  • Phone: 520-384-3541
  • Fax: 520-384-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4754
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: