Provider Demographics
NPI:1528168242
Name:THIELE, JEAN M (CNP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:THIELE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 ROCKWELL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-9316
Mailing Address - Country:US
Mailing Address - Phone:989-633-5350
Mailing Address - Fax:989-633-5340
Practice Address - Street 1:2121 ROCKWELL DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-9316
Practice Address - Country:US
Practice Address - Phone:989-633-5350
Practice Address - Fax:989-633-5340
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJT139745363L00000X
MI4704139745363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P16510001Medicare PIN
MIS43972Medicare UPIN