Provider Demographics
NPI:1427069624
Name:TIEDE, JUDITH ANN (APRN)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:TIEDE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 1ST AVE NE
Mailing Address - Street 2:STE 310
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2419
Mailing Address - Country:US
Mailing Address - Phone:612-302-4600
Mailing Address - Fax:612-302-4870
Practice Address - Street 1:1313 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:612-302-4600
Practice Address - Fax:612-302-4870
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-046467-5163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN147853900Medicaid
MN89000293Medicare ID - Type UnspecifiedMEDICARE
MN147853900Medicaid