Provider Demographics
NPI:1619032158
Name:TIETZ, PAMELA MARIE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MARIE
Last Name:TIETZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:MARIE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP APRN
Mailing Address - Street 1:618 ROLLING MEADOWS LN SE
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-4022
Mailing Address - Country:US
Mailing Address - Phone:952-758-2908
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 109339-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P89737Medicare UPIN