Provider Demographics
NPI:1588706261
Name:THIESZEN, MAURINE (RD)
Entity type:Individual
Prefix:
First Name:MAURINE
Middle Name:
Last Name:THIESZEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51449-1585
Mailing Address - Country:US
Mailing Address - Phone:712-464-3171
Mailing Address - Fax:712-464-3269
Practice Address - Street 1:1301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:IA
Practice Address - Zip Code:51449-1585
Practice Address - Country:US
Practice Address - Phone:712-464-3171
Practice Address - Fax:712-464-3269
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00509133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI7160Medicare PIN