Healthcare Provider Details

I. General information

NPI: 1639421563
Provider Name (Legal Business Name): MICHELE TIBBO ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 OBRECHT RD
SYKESVILLE MD
21784-7628
US

IV. Provider business mailing address

416 OBRECHT RD
SYKESVILLE MD
21784-7628
US

V. Phone/Fax

Practice location:
  • Phone: 410-458-9400
  • Fax:
Mailing address:
  • Phone: 410-458-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR131381
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: