Provider Demographics
NPI:1659670099
Name:WADDELL TIBERIO, JANE E (RN)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:E
Last Name:WADDELL TIBERIO
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 1:7334 SLOCUM RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-9751
Mailing Address - Country:US
Mailing Address - Phone:315-333-5459
Mailing Address - Fax:
Practice Address - Street 1:7334 SLOCUM RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9751
Practice Address - Country:US
Practice Address - Phone:315-333-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY484843-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse