Provider Demographics
NPI:1992916548
Name:TIEDEMAN, SHARLYN JO (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHARLYN
Middle Name:JO
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHARLYN
Other - Middle Name:JO
Other - Last Name:TRIGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 162
Mailing Address - Street 2:1448 160TH ST
Mailing Address - City:LAKE BENTON
Mailing Address - State:MN
Mailing Address - Zip Code:56149
Mailing Address - Country:US
Mailing Address - Phone:507-368-4274
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0521275164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse