Provider Demographics
NPI:1316989494
Name:LIEBELT, GRETA JONES (NP)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:JONES
Last Name:LIEBELT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:H
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:888-620-3100
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:2105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1425
Practice Address - Country:US
Practice Address - Phone:408-947-2500
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN594412Medicaid
CAQ33464Medicare UPIN
CAZZZ32166ZMedicare ID - Type Unspecified