Provider Demographics
NPI:1366038119
Name:LIBERONA OUELLETTE, SUSANA HAYDEE (NURSE)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:HAYDEE
Last Name:LIBERONA OUELLETTE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 OAKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-4041
Mailing Address - Country:US
Mailing Address - Phone:319-321-5493
Mailing Address - Fax:
Practice Address - Street 1:1001 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-4041
Practice Address - Country:US
Practice Address - Phone:319-321-5493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP59924164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse