Provider Demographics
NPI:1174030506
Name:REBELLO, SIBLE
Entity Type:Individual
Prefix:
First Name:SIBLE
Middle Name:
Last Name:REBELLO
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 1:3660 PARK SIERRA DR STE 203
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3071
Mailing Address - Country:US
Mailing Address - Phone:951-687-3400
Mailing Address - Fax:951-687-7630
Practice Address - Street 1:3660 PARK SIERRA DR STE 208
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3071
Practice Address - Country:US
Practice Address - Phone:951-687-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95007845363LA2200X
CA95007845363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty