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NPI Code Detail

MEDICARE: MRS. LISA ANN TIEBAUER PMHNP-BC

MEDICARE: MRS. LISA ANN TIEBAUER PMHNP-BC
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner5005198NC

General Provider Information

NPI Number : 1700069044
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. LISA ANN TIEBAUER PMHNP-BC
Provider Business Mailing Address
First Line : 200 TARPON TRL
Second Line :
City : JACKSONVILLE
State : NC
Zip : 28546-5287
Country : US
Telephone Number : 910-938-1114
Fax Number : 910-938-1118
Provider Business Practice Location Address
First Line : 200 TARPON TRL
Second Line :
City : JACKSONVILLE
State : NC
Zip : 28546-5287
Country : US
Telephone Number : 910-938-1114
Fax Number : 910-938-1118
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/10/2007
Last Update Date : 03/07/2023

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