Healthcare Provider Details

I. General information

NPI: 1568179513
Provider Name (Legal Business Name): KATHRYN WALLER LIEBING CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN CHRISTINE WALLER

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506A MONTGOMERY ROAD SUITE 200
MONTGOMERY OH
45242-4400
US

IV. Provider business mailing address

10506A MONTGOMERY ROAD SUITE 200
MONTGOMERY OH
45242-4400
US

V. Phone/Fax

Practice location:
  • Phone: 513-246-2343
  • Fax: 513-246-4047
Mailing address:
  • Phone: 513-246-2343
  • Fax: 513-246-4047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number32767
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0037558
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: