Provider Demographics
NPI:1346213758
Name:THIESSEN, KELLIE R (CNM,MS)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:R
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:CNM,MS
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 3055
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-3055
Mailing Address - Country:US
Mailing Address - Phone:605-867-2052
Mailing Address - Fax:
Practice Address - Street 1:1201 E. HWY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-3003
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD036OtherCERTIFIED NURSE MIDWIFE