Provider Demographics
NPI:1992280622
Name:SIBANDA, OTTILIA (NP)
Entity type:Individual
Prefix:
First Name:OTTILIA
Middle Name:
Last Name:SIBANDA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 WILLESDEN GREEN CT
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3329
Mailing Address - Country:US
Mailing Address - Phone:870-680-3768
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-657-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24778363LF0000X, 363LP0808X
AZ269865363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily