Provider Demographics
NPI:1629850813
Name:SEBULIBA, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SEBULIBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 NEIL ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-2835
Mailing Address - Country:US
Mailing Address - Phone:781-475-0531
Mailing Address - Fax:
Practice Address - Street 1:11 APEX DR STE 300A
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1977
Practice Address - Country:US
Practice Address - Phone:781-888-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN95431164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse