Provider Demographics
NPI:1093253908
Name:THIESSEN, PATRICIA CAROL (OMD, LAC)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:CAROL
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S MOUNT SHASTA BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2559
Mailing Address - Country:US
Mailing Address - Phone:530-938-3442
Mailing Address - Fax:
Practice Address - Street 1:407 S MOUNT SHASTA BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2559
Practice Address - Country:US
Practice Address - Phone:530-938-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3493171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist