Provider Demographics
NPI:1912250242
Name:LIEBERMAN, BRENDALYNN IJEOMA-IBE (NP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDALYNN
Middle Name:IJEOMA-IBE
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:950 VICTORS WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-926-4800
Mailing Address - Fax:
Practice Address - Street 1:840 MAUS AVENUE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-485-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704249739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704249739OtherLICENSE NUMBER