Provider Demographics
NPI:1083034110
Name:NIESZ, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:NIESZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9441 LBJ FWY
Mailing Address - Street 2:602
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4545
Mailing Address - Country:US
Mailing Address - Phone:888-800-8744
Mailing Address - Fax:
Practice Address - Street 1:9441 LBJ FWY
Practice Address - Street 2:602
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-4545
Practice Address - Country:US
Practice Address - Phone:888-800-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH77185291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory