Healthcare Provider Details

I. General information

NPI: 1790927549
Provider Name (Legal Business Name): TIFFANY LISA LIEURANCE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N CARRIAGE PKWY
WICHITA KS
67208-4508
US

IV. Provider business mailing address

800 N CARRIAGE PKWY
WICHITA KS
67208-4508
US

V. Phone/Fax

Practice location:
  • Phone: 316-858-5800
  • Fax: 316-858-5868
Mailing address:
  • Phone: 316-858-5800
  • Fax: 316-858-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006016929
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0533813
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: