Provider Demographics
NPI:1194096933
Name:TYBORSKI, ROBERTA J
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:TYBORSKI
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 1:919 ALABAMA PL APT 9
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1169
Mailing Address - Country:US
Mailing Address - Phone:920-559-2009
Mailing Address - Fax:
Practice Address - Street 1:919 ALABAMA PL APT 9
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1169
Practice Address - Country:US
Practice Address - Phone:920-559-2009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314609-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse