Provider Demographics
NPI:1336161470
Name:LIEBENTRITT, NICOLE M (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:LIEBENTRITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10020 NICHOLAS STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2188
Mailing Address - Country:US
Mailing Address - Phone:402-393-2023
Mailing Address - Fax:402-393-3244
Practice Address - Street 1:10020 NICHOLAS STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-393-2023
Practice Address - Fax:402-393-3244
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE232332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0592485OtherMEDICAID INDIVIDUAL
NE30039OtherBC/BS INDIVIDUAL
NE470542490OtherTRICARE GROUP
NE01907OtherBC/BS GROUP
NE247248OtherMIDLANDS CHOICE
NE47054249013Medicaid
NE47054249012Medicaid
NE05-00466OtherSHARE ADVANTAGE LAKESIDE
NE05-00454OtherSHARE ADVANTAGE - BERGAN
NEP00239606OtherRR MEDICARE INDIVIDUAL
NE470542490OtherTRICARE GROUP
NE47054249012Medicaid
NEP00239606OtherRR MEDICARE INDIVIDUAL