Provider Demographics
NPI:1306864954
Name:SMITH, SYBILLE GOLDBACK (ARNP)
Entity Type:Individual
Prefix:
First Name:SYBILLE
Middle Name:GOLDBACK
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW
Mailing Address - Street 2:STE 100
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3071
Mailing Address - Country:US
Mailing Address - Phone:253-581-6688
Mailing Address - Fax:253-512-2894
Practice Address - Street 1:11311 BRIDGEPORT WAY SW
Practice Address - Street 2:STE 100
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3071
Practice Address - Country:US
Practice Address - Phone:253-581-6688
Practice Address - Fax:253-512-2894
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005537163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
8929404OtherSTATE CRIME VICTIMS
WAP00306321OtherRAILROAD
WA9627324Medicaid
0193324OtherSTATE LICENSE
WAP00306321OtherRAILROAD
8929404OtherSTATE CRIME VICTIMS
WAG8869021Medicare PIN
WAG8858439Medicare PIN