Provider Demographics
NPI:1427691468
Name:LIBBY, KATHYRN JILL
Entity type:Individual
Prefix:
First Name:KATHYRN
Middle Name:JILL
Last Name:LIBBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:LIBBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, FNP-BC
Mailing Address - Street 1:4614 LEHRER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1213
Mailing Address - Country:US
Mailing Address - Phone:619-804-8823
Mailing Address - Fax:
Practice Address - Street 1:1249 E OHIO AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-3053
Practice Address - Country:US
Practice Address - Phone:760-385-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine