Provider Demographics
NPI:1902533128
Name:NYBO, MARANDA SUE
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:SUE
Last Name:NYBO
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 1:10381 OLD SIDNEY RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-8426
Mailing Address - Country:US
Mailing Address - Phone:228-669-5645
Mailing Address - Fax:
Practice Address - Street 1:6340 KILN DELISLE RD STE C
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-9719
Practice Address - Country:US
Practice Address - Phone:228-363-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-07
Last Update Date:2022-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty