Healthcare Provider Details

I. General information

NPI: 1912482118
Provider Name (Legal Business Name): JESSICA CAROLINE THIENES DNP, APRN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

2124 COMO AVE APT 104
SAINT PAUL MN
55108-1830
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number383
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: