Provider Demographics
NPI:1386342236
Name:NIEBLA, LYDIA
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:NIEBLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 STAR CROSS TRL
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4049
Mailing Address - Country:US
Mailing Address - Phone:210-621-8521
Mailing Address - Fax:
Practice Address - Street 1:8210 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3923
Practice Address - Country:US
Practice Address - Phone:210-450-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39918900OtherDRIVERS LICENSE