Provider Demographics
NPI:1306454053
Name:THIEDE, SAMANTHA L (APNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:THIEDE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1788
Mailing Address - Country:US
Mailing Address - Phone:920-324-6801
Mailing Address - Fax:920-324-8439
Practice Address - Street 1:608 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1788
Practice Address - Country:US
Practice Address - Phone:920-324-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10152363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner