Provider Demographics
NPI:1104387570
Name:TIBBLES, CASSIA
Entity Type:Individual
Prefix:
First Name:CASSIA
Middle Name:
Last Name:TIBBLES
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 1:7 CERQUA STREET
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801
Mailing Address - Country:US
Mailing Address - Phone:603-769-1542
Mailing Address - Fax:
Practice Address - Street 1:7 CERQUA ST
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-5302
Practice Address - Country:US
Practice Address - Phone:603-769-1542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2020-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH067704-21363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH067704-23OtherAPRN
NH067704-21OtherRN