Provider Demographics
NPI:1265401269
Name:THIELEN, AMANDA TUTTLE (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:TUTTLE
Last Name:THIELEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:2620 EAGAN WOODS DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1138
Practice Address - Country:US
Practice Address - Phone:651-968-5230
Practice Address - Fax:651-994-3982
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65372251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00019025OtherRAILROAD MEDICARE
MNP00019025OtherRAILROAD MEDICARE