Provider Demographics
NPI:1912406422
Name:KIBLER, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KIBLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 KETTERING DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-2228
Mailing Address - Country:US
Mailing Address - Phone:716-812-9499
Mailing Address - Fax:
Practice Address - Street 1:1001 11TH ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1201
Practice Address - Country:US
Practice Address - Phone:716-278-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY654123163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-0975994Medicaid