Healthcare Provider Details

I. General information

NPI: 1265678049
Provider Name (Legal Business Name): JOMO TIBBY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2008
Last Update Date: 12/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 HUTCHINSON RIVER PKWY E APT 6D
BRONX NY
10475-4741
US

IV. Provider business mailing address

4220 HUTCHINSON RIVER PKWY E APT 6D
BRONX NY
10475-4741
US

V. Phone/Fax

Practice location:
  • Phone: 646-261-0832
  • Fax:
Mailing address:
  • Phone: 646-261-0832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number593995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: