Provider Demographics
NPI:1841605714
Name:LIETZKE, MARIE S (RN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:S
Last Name:LIETZKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:S
Other - Last Name:SWANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4295 10TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3111
Mailing Address - Country:US
Mailing Address - Phone:951-312-8952
Mailing Address - Fax:
Practice Address - Street 1:1224 VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1612
Practice Address - Country:US
Practice Address - Phone:323-769-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA773969163W00000X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse