Healthcare Provider Details

I. General information

NPI: 1982949137
Provider Name (Legal Business Name): LAURA TIEHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE C300J
DALLAS TX
75230-2604
US

IV. Provider business mailing address

7777 FOREST LN STE C300J
DALLAS TX
75230-2604
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-7730
  • Fax: 972-566-7437
Mailing address:
  • Phone: 972-566-7730
  • Fax: 972-566-7437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number747065
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: