Healthcare Provider Details

I. General information

NPI: 1942089206
Provider Name (Legal Business Name): MICHELLE RAINA TIBBENS MSN, APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 RUN SWAMP RD
CAMDEN NC
27921-7625
US

IV. Provider business mailing address

102 RUN SWAMP RD
CAMDEN NC
27921-7625
US

V. Phone/Fax

Practice location:
  • Phone: 814-553-2117
  • Fax:
Mailing address:
  • Phone: 814-553-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024188279
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: