Healthcare Provider Details

I. General information

NPI: 1841020518
Provider Name (Legal Business Name): NICOLE LYBBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 S 2ND E
REXBURG ID
83440-1906
US

IV. Provider business mailing address

1148 COYOTE WILLOW WAY
REXBURG ID
83440-5271
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number62400
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: