Provider Demographics
NPI:1093324436
Name:TIBBS, DWANA
Entity Type:Individual
Prefix:
First Name:DWANA
Middle Name:
Last Name:TIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 HIGHWAY 115
Mailing Address - Street 2:
Mailing Address - City:BUNKIE
Mailing Address - State:LA
Mailing Address - Zip Code:71322-4311
Mailing Address - Country:US
Mailing Address - Phone:337-336-9794
Mailing Address - Fax:
Practice Address - Street 1:4213 HIGHWAY 115
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-4311
Practice Address - Country:US
Practice Address - Phone:337-336-9794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA210538164W00000X
LA211294163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse