=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871825497
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STANLEY TITANG TIBONG DNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2010
-----------------------------------------------------
Last Update Date | 10/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 E APPLE ST STE 5254A
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409-2939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-208-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6626 WOODLAND TRACE CT
-----------------------------------------------------
City | LIBERTY TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45044-9172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-382-4927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN. 344514
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.15133
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------