Provider Demographics
NPI:1588705552
Name:LIEBERT, REBECCA A (APN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:LIEBERT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 GOPHER DR
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-4513
Mailing Address - Country:US
Mailing Address - Phone:608-372-2181
Mailing Address - Fax:608-374-6648
Practice Address - Street 1:2300 W SAHARA AVE STE 800
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4397
Practice Address - Country:US
Practice Address - Phone:203-666-8145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2751363L00000X
NV829613363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2751OtherSTATE LICENSE