Provider Demographics
NPI:1023148012
Name:LIEBMAN, DONDRA MARY (LPN)
Entity type:Individual
Prefix:
First Name:DONDRA
Middle Name:MARY
Last Name:LIEBMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29148 COUNTY ROUTE 56
Mailing Address - Street 2:
Mailing Address - City:CAPE VINCENT
Mailing Address - State:NY
Mailing Address - Zip Code:13618
Mailing Address - Country:US
Mailing Address - Phone:315-654-4711
Mailing Address - Fax:
Practice Address - Street 1:29148 COUNTY ROUTE 56
Practice Address - Street 2:
Practice Address - City:CAPE VINCENT
Practice Address - State:NY
Practice Address - Zip Code:13618
Practice Address - Country:US
Practice Address - Phone:315-654-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283861164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02749526Medicaid