Provider Demographics
NPI:1437380136
Name:TIEDE, KIMBERLEY K (LPN)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:K
Last Name:TIEDE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2492 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:NY
Mailing Address - Zip Code:14530-9622
Mailing Address - Country:US
Mailing Address - Phone:585-259-6218
Mailing Address - Fax:
Practice Address - Street 1:2492 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:NY
Practice Address - Zip Code:14530-9622
Practice Address - Country:US
Practice Address - Phone:585-259-6218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233646164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse