Provider Demographics
NPI:1295171874
Name:LYBBERT, ANGEL KAE (MD)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:KAE
Last Name:LYBBERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-7250
Mailing Address - Fax:
Practice Address - Street 1:395 W. BULLDOG BLVD. SUITE 6B
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-357-7250
Practice Address - Fax:801-357-7198
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9116912-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine