Provider Demographics
NPI:1659990331
Name:MATERLA, SYBILLA
Entity Type:Individual
Prefix:
First Name:SYBILLA
Middle Name:
Last Name:MATERLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20694 KEYSTONE AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6175
Mailing Address - Country:US
Mailing Address - Phone:612-323-9989
Mailing Address - Fax:
Practice Address - Street 1:20694 KEYSTONE AVE UNIT C
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6175
Practice Address - Country:US
Practice Address - Phone:612-323-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN817084164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse