Provider Demographics
NPI:1649759861
Name:TIEDGE, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:TIEDGE
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 1:65 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 PARK AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1040
Practice Address - Country:US
Practice Address - Phone:631-512-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist