MEDICARE: JUDITH A TIBERIA ARNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN2927142	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	Y7196	OTHER	FL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811982473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH A TIBERIA ARNP

Provider Business Mailing Address
First Line	:	3191 HARBOR BLVD STE A
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6755
Country	:	US
Telephone Number	:	941-766-9555
Fax Number	:	941-766-1511

Provider Business Practice Location Address
First Line	:	3191 HARBOR BLVD STE A
Second Line	:	SUITE A
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6755
Country	:	US
Telephone Number	:	941-766-9555
Fax Number	:	941-766-1511

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	06/06/2019

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