Healthcare Provider Details

I. General information

NPI: 1528556982
Provider Name (Legal Business Name): SUSAN JANE LIES MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 CEDAR ST
SOUTH BEND IN
46617-2054
US

IV. Provider business mailing address

28900 STATE ROAD 2
NEW CARLISLE IN
46552-9742
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-4694
  • Fax:
Mailing address:
  • Phone: 574-807-1272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number28209958A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: