Provider Demographics
NPI:1811982473
Name:TIBERIA, JUDITH A (ARNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:TIBERIA
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 1:3191 HARBOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6755
Mailing Address - Country:US
Mailing Address - Phone:941-766-9555
Mailing Address - Fax:941-766-1511
Practice Address - Street 1:3191 HARBOR BLVD STE A
Practice Address - Street 2:SUITE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6755
Practice Address - Country:US
Practice Address - Phone:941-766-9555
Practice Address - Fax:941-766-1511
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN2927142363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300323000Medicaid
FLY7196OtherBCBS
FLY7196OtherBCBS
S51911Medicare UPIN