Basic Information
| Provider Information | |||||||||
| NPI: | 1871825497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBONG | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | TITANG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 WOODLAND TRACE CT | ||||||||
| Address2: | |||||||||
| City: | LIBERTY TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450449172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133824927 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 E APPLE ST STE 5254A | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2010 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN. 344514 | OH | N | Nursing Service Providers | Registered Nurse | 363L00000X | APRN.CNP.15133 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0094838 | 05 | OH | MEDICAID |