Provider Demographics
NPI:1386008449
Name:TIBBETTS, AMBER (LPN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:COLBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4325 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2730
Mailing Address - Country:US
Mailing Address - Phone:218-722-1497
Mailing Address - Fax:
Practice Address - Street 1:4325 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2730
Practice Address - Country:US
Practice Address - Phone:218-722-1497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL075209-9164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse