Provider Demographics
NPI:1205475209
Name:TIEDERMAN, TERRI LYNN (RN)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:TIEDERMAN
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 1:890 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-701-8224
Mailing Address - Fax:
Practice Address - Street 1:CNS HEALTHCARE 24230 KARIM BLVD
Practice Address - Street 2:STE 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:248-994-8005
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254506163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse