Provider Demographics
NPI:1689260929
Name:RIEBE-MICKENS, LISA LYNN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:RIEBE-MICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14952 MERMILL RD
Mailing Address - Street 2:
Mailing Address - City:RUDOLPH
Mailing Address - State:OH
Mailing Address - Zip Code:43462-9624
Mailing Address - Country:US
Mailing Address - Phone:419-277-4058
Mailing Address - Fax:
Practice Address - Street 1:14952 MERMILL RD
Practice Address - Street 2:
Practice Address - City:RUDOLPH
Practice Address - State:OH
Practice Address - Zip Code:43462-9624
Practice Address - Country:US
Practice Address - Phone:419-277-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker