Provider Demographics
NPI:1568650190
Name:TIESZEN, MARY LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LYNN
Last Name:TIESZEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 W MCDOWELL RD
Mailing Address - Street 2:STE. 209
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2624
Mailing Address - Country:US
Mailing Address - Phone:623-512-4310
Mailing Address - Fax:623-512-4311
Practice Address - Street 1:13555 W MCDOWELL RD
Practice Address - Street 2:STE. 209
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2624
Practice Address - Country:US
Practice Address - Phone:623-512-4310
Practice Address - Fax:623-512-4311
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN104549363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily