Provider Demographics
NPI:1932506227
Name:TIETJEN, ANNALISA I
Entity Type:Individual
Prefix:
First Name:ANNALISA
Middle Name:
Last Name:TIETJEN
Suffix:I
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 1:5150 NW MILNER DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3392
Mailing Address - Country:US
Mailing Address - Phone:772-462-3800
Mailing Address - Fax:772-462-3801
Practice Address - Street 1:714 AVE C
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:32909
Practice Address - Country:US
Practice Address - Phone:772-462-3800
Practice Address - Fax:772-462-3801
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH17092124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist