Healthcare Provider Details

I. General information

NPI: 1902896632
Provider Name (Legal Business Name): JACQUELINE DENISE LIBERATI B.S., RN, MSN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD ROBERT WOOD BUILDING 1ST FLOOR
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

221 GREENBRIAR LN
HAVERTOWN PA
19083-2847
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-3440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP008107
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN543487
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR11548300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-56479
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: