Healthcare Provider Details

I. General information

NPI: 1427069624
Provider Name (Legal Business Name): JUDITH ANN TIEDE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 PENN AVE N
MINNEAPOLIS MN
55411-3047
US

IV. Provider business mailing address

615 1ST AVE NE STE 310
MINNEAPOLIS MN
55413-2419
US

V. Phone/Fax

Practice location:
  • Phone: 612-302-4600
  • Fax: 612-302-4870
Mailing address:
  • Phone: 612-302-4600
  • Fax: 612-302-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR-046467-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: