Provider Demographics
NPI:1578763967
Name:TIEDEMAN, ANNIE ELIZABETH (LMP)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:ELIZABETH
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10802 EAGLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:WA
Mailing Address - Zip Code:98826-9116
Mailing Address - Country:US
Mailing Address - Phone:509-548-1531
Mailing Address - Fax:
Practice Address - Street 1:11779 HIGHWAY 2
Practice Address - Street 2:SUITE 104
Practice Address - City:LEAVENWORTH
Practice Address - State:WA
Practice Address - Zip Code:98826-1362
Practice Address - Country:US
Practice Address - Phone:509-548-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024507174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist