Provider Demographics
NPI:1790135481
Name:THIES, DIEDRA
Entity Type:Individual
Prefix:
First Name:DIEDRA
Middle Name:
Last Name:THIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIEDRA
Other - Middle Name:ANN
Other - Last Name:ARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68503-1803
Mailing Address - Country:US
Mailing Address - Phone:402-476-1455
Mailing Address - Fax:402-476-1670
Practice Address - Street 1:1021 N 27TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-1803
Practice Address - Country:US
Practice Address - Phone:402-476-1455
Practice Address - Fax:402-476-1670
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025024300Medicaid
NE10025024400Medicaid
NE099471Medicare PIN