Provider Demographics
NPI:1659087765
Name:LIEBAU, KELLIE MARIE (RN)
Entity Type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:MARIE
Last Name:LIEBAU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15847 SABRE
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-2742
Mailing Address - Country:US
Mailing Address - Phone:586-872-4328
Mailing Address - Fax:
Practice Address - Street 1:15847 SABRE
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-2742
Practice Address - Country:US
Practice Address - Phone:586-872-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704376334163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse