Provider Demographics
NPI:1316682321
Name:TIEDJE, NIKKI (RN, MSN, CCNS)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:TIEDJE
Suffix:
Gender:F
Credentials:RN, MSN, CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5471
Mailing Address - Country:US
Mailing Address - Phone:312-491-8441
Mailing Address - Fax:
Practice Address - Street 1:1072 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5471
Practice Address - Country:US
Practice Address - Phone:312-491-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041328791163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse