Provider Demographics
NPI:1154627297
Name:THEISEN, DEDRA LEE (RN)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:LEE
Last Name:THEISEN
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 1:14315 305TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-3648
Mailing Address - Country:US
Mailing Address - Phone:612-987-0234
Mailing Address - Fax:
Practice Address - Street 1:14315 305TH AVE NW
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-3648
Practice Address - Country:US
Practice Address - Phone:612-987-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 185363-8163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse