Provider Demographics
NPI:1225395999
Name:TIEDEKEN, SHANNON DOYLE (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DOYLE
Last Name:TIEDEKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:101 APPLIED BANK BLVD STE 11
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS, GLEN MILLS URGENT CARE
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-3501
Practice Address - Country:US
Practice Address - Phone:484-800-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics