Provider Demographics
NPI:1629473483
Name:DIBAL, MBWIDIFFU A (NP-C)
Entity Type:Individual
Prefix:
First Name:MBWIDIFFU
Middle Name:A
Last Name:DIBAL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MBWIDIFFU
Other - Middle Name:
Other - Last Name:SALMAMZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4001 MILLER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-1961
Mailing Address - Country:US
Mailing Address - Phone:302-407-5222
Mailing Address - Fax:302-407-5221
Practice Address - Street 1:4001 MILLER RD STE 1
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-1961
Practice Address - Country:US
Practice Address - Phone:302-407-5222
Practice Address - Fax:302-407-5221
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000757363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE200141998Medicaid