Provider Demographics
NPI:1710338744
Name:SIBBALUCA, KAYLA (ATC)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:SIBBALUCA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 POWDERHORN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-2743
Mailing Address - Country:US
Mailing Address - Phone:707-536-7888
Mailing Address - Fax:
Practice Address - Street 1:201 FAIR ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2516
Practice Address - Country:US
Practice Address - Phone:707-778-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000025463174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist