Provider Demographics
NPI:1669556379
Name:LIEBERT, CARLYN M (ARNP)
Entity type:Individual
Prefix:
First Name:CARLYN
Middle Name:M
Last Name:LIEBERT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:425-455-2845
Mailing Address - Fax:
Practice Address - Street 1:22707 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9532
Practice Address - Country:US
Practice Address - Phone:425-455-2845
Practice Address - Fax:425-861-8602
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP3000651363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9600149Medicaid
WAAB40131Medicare PIN
WA9600149Medicaid