Provider Demographics
NPI:1770362154
Name:SULLEY, LIBABATU
Entity type:Individual
Prefix:
First Name:LIBABATU
Middle Name:
Last Name:SULLEY
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 1:11212 BLACK FOOT CT
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1492
Mailing Address - Country:US
Mailing Address - Phone:240-481-8228
Mailing Address - Fax:
Practice Address - Street 1:11212 BLACK FOOT CT
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1492
Practice Address - Country:US
Practice Address - Phone:240-481-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily