Provider Demographics
NPI:1801317789
Name:TUDELA, MARIDEE TA'TIERRA
Entity type:Individual
Prefix:
First Name:MARIDEE
Middle Name:TA'TIERRA
Last Name:TUDELA
Suffix:
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 1:4939 PERIWINKLE DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-5000
Mailing Address - Country:US
Mailing Address - Phone:503-851-2705
Mailing Address - Fax:
Practice Address - Street 1:3876 BEVERLY AVE NE BLDG G
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1319
Practice Address - Country:US
Practice Address - Phone:503-763-5735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist