1265916845 NPI number — DR. LISA TIEBER NIELSON DVM

Table of content: GABRIELA FLANNERY RDH (NPI 1770868432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265916845 NPI number — DR. LISA TIEBER NIELSON DVM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIEBER NIELSON
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DVM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIEBER
Provider Other First Name:
LISA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1265916845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95492-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 MISSION BELL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN PABLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94806-3195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-235-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  17019 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)