Provider Demographics
NPI:1558324772
Name:LIBBY, JONATHAN (DNP, APRN, CPNP)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:DNP, APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10187
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-5187
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:100 CAMPUS AVE APT 203
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6079
Practice Address - Country:US
Practice Address - Phone:207-755-3160
Practice Address - Fax:207-755-3166
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME041889363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME245420099Medicaid