Provider Demographics
NPI:1225627847
Name:LIEBURN, EMILY A (RD, CD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:LIEBURN
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:A
Other - Last Name:JORGENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:6721 N 99TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-5217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-7782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3169-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered