Provider Demographics
NPI:1164567970
Name:LIEBL, KRISTEN M (LRD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:LIEBL
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:SPAETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-2245
Mailing Address - Fax:701-234-3838
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-2245
Practice Address - Fax:701-234-3838
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND674132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51556Medicaid
ND712464Medicare PIN