MEDICARE: NICOLE BIANCA SAN JUAN LIBIRAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	390200000X

General Provider Information

NPI Number	:	1659189199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BIANCA SAN JUAN LIBIRAN

Provider Business Mailing Address
First Line	:	10684 ERIE DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9454
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10684 ERIE DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9454
Country	:	US
Telephone Number	:	219-776-3489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2024
Last Update Date	:	12/30/2024

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Directions to “ NICOLE BIANCA SAN JUAN LIBIRAN ” Practice Location

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