Provider Demographics
NPI:1487824660
Name:LIBERATOR, LORI KAY (FNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:KAY
Last Name:LIBERATOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:KAY
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2840 N DYSART RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2338
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-652-9787
Practice Address - Street 1:2840 N DYSART RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2338
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ315113Medicaid