Provider Demographics
NPI:1376575829
Name:LALIBERTE, SUSAN JANE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JANE
Last Name:LALIBERTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-573-6165
Practice Address - Street 1:3536 MENDOCINO AVE
Practice Address - Street 2:STE 200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3634
Practice Address - Country:US
Practice Address - Phone:707-573-6166
Practice Address - Fax:707-573-6165
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF7780363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00328596OtherRAILROAD MEDICARE
CARN321590Medicaid
CAZZZ02480ZMedicare PIN
CACE277ZMedicare PIN
CARN321590Medicaid