Healthcare Provider Details

I. General information

NPI: 1104387570
Provider Name (Legal Business Name): CASSIA TIBBLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 02/23/2020
Certification Date: 02/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 CERQUA ST
WOBURN MA
01801-5302
US

IV. Provider business mailing address

7 CERQUA STREET
WOBURN MA
01801
US

V. Phone/Fax

Practice location:
  • Phone: 603-769-1542
  • Fax:
Mailing address:
  • Phone: 603-769-1542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number067704-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: