Healthcare Provider Details

I. General information

NPI: 1538801709
Provider Name (Legal Business Name): ANTHONY TIEDEMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 S 56TH AVE STE 1B
PHOENIX AZ
85043-4630
US

IV. Provider business mailing address

806 S 56TH AVE STE 1B
PHOENIX AZ
85043-4630
US

V. Phone/Fax

Practice location:
  • Phone: 602-429-0447
  • Fax:
Mailing address:
  • Phone: 602-429-0447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: