Healthcare Provider Details

I. General information

NPI: 1295779387
Provider Name (Legal Business Name): STACIE NOEL LIEBELT F.N P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 N STAR WAY STE A
MODESTO CA
95356-8628
US

IV. Provider business mailing address

4335 N STAR WAY STE A
MODESTO CA
95356-8628
US

V. Phone/Fax

Practice location:
  • Phone: 209-342-5125
  • Fax: 209-342-5128
Mailing address:
  • Phone: 209-342-5125
  • Fax: 209-342-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: