Provider Demographics
NPI:1851959423
Name:TIEDEMAN, KERRI LEIGH
Entity type:Individual
Prefix:MRS
First Name:KERRI
Middle Name:LEIGH
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 KENSAL RISE PL
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-9654
Mailing Address - Country:US
Mailing Address - Phone:405-620-0121
Mailing Address - Fax:
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6697
Practice Address - Country:US
Practice Address - Phone:405-364-5020
Practice Address - Fax:405-364-5021
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist