Provider Demographics
NPI:1104377191
Name:THIESSEN, ERICA JOAN
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:JOAN
Last Name:THIESSEN
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 1:1632 FORESTBURGH RD
Mailing Address - Street 2:
Mailing Address - City:GLEN SPEY
Mailing Address - State:NY
Mailing Address - Zip Code:12737-5250
Mailing Address - Country:US
Mailing Address - Phone:845-665-1237
Mailing Address - Fax:
Practice Address - Street 1:1632 FORESTBURGH RD
Practice Address - Street 2:
Practice Address - City:GLEN SPEY
Practice Address - State:NY
Practice Address - Zip Code:12737-5250
Practice Address - Country:US
Practice Address - Phone:845-665-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322618-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse