Provider Demographics
NPI:1205334059
Name:LIBERTY, MANDY S (RN)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:S
Last Name:LIBERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MANDY
Other - Middle Name:S
Other - Last Name:TANTUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2250 HICKORY ROAD SUITE 240
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462
Mailing Address - Country:US
Mailing Address - Phone:800-879-4471
Mailing Address - Fax:
Practice Address - Street 1:5809 MAIN STREET
Practice Address - Street 2:ST VINCENT DE PAUL REGIONAL SCHOOL
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330
Practice Address - Country:US
Practice Address - Phone:609-625-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO11756000163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse