Provider Demographics
NPI:1306558770
Name:NAKIBERU, MOLLY N/A
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:N/A
Last Name:NAKIBERU
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 1:211 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01518-1024
Mailing Address - Country:US
Mailing Address - Phone:508-215-9602
Mailing Address - Fax:
Practice Address - Street 1:211 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01518-1024
Practice Address - Country:US
Practice Address - Phone:508-218-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN88641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1869Medicaid