Provider Demographics
NPI:1295064921
Name:SEBULIBA, MATTHEW (RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SEBULIBA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 N MOHAWK AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5027
Mailing Address - Country:US
Mailing Address - Phone:414-817-2055
Mailing Address - Fax:
Practice Address - Street 1:5319 N MOHAWK AVE APT 2
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-5027
Practice Address - Country:US
Practice Address - Phone:414-817-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157766-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse