Provider Demographics
NPI:1861853566
Name:LIDBURY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LIDBURY
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:N2150 KESAEHKAHTEK
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:WI
Mailing Address - Zip Code:54128
Mailing Address - Country:US
Mailing Address - Phone:715-799-3835
Mailing Address - Fax:715-799-5056
Practice Address - Street 1:N2150 KESAEHKAHTEK
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:WI
Practice Address - Zip Code:54128
Practice Address - Country:US
Practice Address - Phone:715-799-3835
Practice Address - Fax:715-799-5056
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI169207-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse