Provider Demographics
NPI:1568963866
Name:LIDDELL, MANICIA SHUNDREAL (NP)
Entity Type:Individual
Prefix:
First Name:MANICIA
Middle Name:SHUNDREAL
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-2172
Mailing Address - Country:US
Mailing Address - Phone:763-389-1313
Mailing Address - Fax:
Practice Address - Street 1:911 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2172
Practice Address - Country:US
Practice Address - Phone:763-389-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLIDD-8T8QP1363L00000X
LA200056363L00000X
MN8995363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSLIDD-8T8QP1OtherADVANCED NURSING LICENSE