Provider Demographics
NPI:1750930723
Name:TIEMAN, NICOLE RENEE (RPH)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENEE
Last Name:TIEMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5408 ROGER DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-8093
Mailing Address - Country:US
Mailing Address - Phone:715-218-2249
Mailing Address - Fax:
Practice Address - Street 1:4300 RIB MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-6604
Practice Address - Country:US
Practice Address - Phone:715-359-6877
Practice Address - Fax:715-359-0241
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12507-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist