Provider Demographics
NPI:1508097247
Name:LIEM, AGNES (CPNP-PC, AE-C)
Entity Type:Individual
Prefix:MS
First Name:AGNES
Middle Name:
Last Name:LIEM
Suffix:
Gender:F
Credentials:CPNP-PC, AE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 MISSILE AVE
Mailing Address - Street 2:
Mailing Address - City:MINOT AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58701
Mailing Address - Country:US
Mailing Address - Phone:701-723-5138
Mailing Address - Fax:
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:701-723-5138
Practice Address - Fax:609-754-9195
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY601494-1163W00000X
VT026.0042618163W00000X
NYF382111-1363LP0200X
NDR43064363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse