Provider Demographics
NPI:1336519198
Name:SIBBOLD, SHELLEY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SIBBOLD
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4684 WENMAR DR.
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4684 WENMAR DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2817
Practice Address - Country:US
Practice Address - Phone:989-793-1095
Practice Address - Fax:989-793-7649
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279434363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics