Provider Demographics
NPI:1932475092
Name:SIBLEY, CHARLEEN A
Entity Type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:A
Last Name:SIBLEY
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 1:1514 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4131
Mailing Address - Country:US
Mailing Address - Phone:706-616-8072
Mailing Address - Fax:706-812-2401
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-616-8072
Practice Address - Fax:706-812-2401
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered