Provider Demographics
NPI:1083290217
Name:TIETZ, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TIETZ
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 1:3007 GARDENCREST LN
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-4579
Mailing Address - Country:US
Mailing Address - Phone:713-898-6445
Mailing Address - Fax:
Practice Address - Street 1:3007 GARDENCREST LN
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:TX
Practice Address - Zip Code:77539-4579
Practice Address - Country:US
Practice Address - Phone:713-898-6445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032760363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily