Healthcare Provider Details

I. General information

NPI: 1629914452
Provider Name (Legal Business Name): LIDIA MICLEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIDIA CIOBANAS

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKAGGS RD STE 103
BRANSON MO
65616-2062
US

IV. Provider business mailing address

PO BOX 7411626
CHICAGO IL
60674-5626
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026017774
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: