Provider Demographics
NPI:1083969166
Name:TIEDEMANN, ALYSSA ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:ANN
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-1209
Mailing Address - Country:US
Mailing Address - Phone:914-400-5557
Mailing Address - Fax:
Practice Address - Street 1:95 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1637
Practice Address - Country:US
Practice Address - Phone:914-592-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY616890163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse