Healthcare Provider Details

I. General information

NPI: 1811953797
Provider Name (Legal Business Name): CLINTON A. THIEL RN, MSN, MN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 BARNES BOULEVARD
MCCHORD AFB WA
98332
US

IV. Provider business mailing address

690 BARNES BLVD
MCCHORD AFB WA
98332
US

V. Phone/Fax

Practice location:
  • Phone: 253-982-5165
  • Fax: 253-982-8406
Mailing address:
  • Phone: 253-982-5165
  • Fax: 253-982-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00086503
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: