Provider Demographics
NPI:1679512396
Name:TIBERIA, JANET MARY (PNP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:MARY
Last Name:TIBERIA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:MARY
Other - Last Name:CARMODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:2 BAYBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:POESTENKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12140-2309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1092 MADISON AVE
Practice Address - Street 2:PEDIATRICS
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2248
Practice Address - Country:US
Practice Address - Phone:518-525-2445
Practice Address - Fax:518-475-7069
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380750363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01878459Medicaid
NY01878459Medicaid
NYS53273Medicare UPIN