Provider Demographics
NPI:1407977374
Name:OLDHAM-SIBLEY, DESTRY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DESTRY
Middle Name:
Last Name:OLDHAM-SIBLEY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 STONE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5227
Mailing Address - Country:US
Mailing Address - Phone:207-626-3455
Mailing Address - Fax:207-626-7586
Practice Address - Street 1:66 STONE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5227
Practice Address - Country:US
Practice Address - Phone:207-626-3455
Practice Address - Fax:207-626-7586
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC2710101YP2500X
MECNP131060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional