Provider Demographics
NPI:1639123052
Name:TIENTER, ROXIE L
Entity Type:Individual
Prefix:
First Name:ROXIE
Middle Name:L
Last Name:TIENTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KANSAS ST NW
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:MN
Mailing Address - Zip Code:55965-8904
Mailing Address - Country:US
Mailing Address - Phone:507-765-5324
Mailing Address - Fax:
Practice Address - Street 1:405 KANSAS ST NW
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:MN
Practice Address - Zip Code:55965-8904
Practice Address - Country:US
Practice Address - Phone:507-765-5324
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR101606-4363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner