Provider Demographics
NPI:1922714609
Name:LILLIBERG, JEANNINE (RN)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:LILLIBERG
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 1:10467 93RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4112
Mailing Address - Country:US
Mailing Address - Phone:651-488-4655
Mailing Address - Fax:
Practice Address - Street 1:10467 93RD AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4112
Practice Address - Country:US
Practice Address - Phone:651-488-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1379727163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1144260589Medicaid