Provider Demographics
NPI:1760059034
Name:TIETJEN, DEBRA (RN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:TIETJEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-2919
Mailing Address - Country:US
Mailing Address - Phone:518-810-8751
Mailing Address - Fax:
Practice Address - Street 1:1121 FOREST RD
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-1219
Practice Address - Country:US
Practice Address - Phone:518-370-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY437682163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse