Provider Demographics
NPI:1629460340
Name:TIEMANN, DONNA JO (MAR)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:JO
Last Name:TIEMANN
Suffix:
Gender:F
Credentials:MAR
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:JO
Other - Last Name:WOMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAR
Mailing Address - Street 1:2514 SW 58TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-5829
Mailing Address - Country:US
Mailing Address - Phone:479-651-2618
Mailing Address - Fax:
Practice Address - Street 1:2514 SW 58TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-5829
Practice Address - Country:US
Practice Address - Phone:479-651-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid