Provider Demographics
NPI:1457233363
Name:TIEDEMANN, KEENE FULTON
Entity type:Individual
Prefix:
First Name:KEENE
Middle Name:FULTON
Last Name:TIEDEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10007 S 9TH CIR
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-4023
Mailing Address - Country:US
Mailing Address - Phone:402-680-2809
Mailing Address - Fax:
Practice Address - Street 1:10007 S 9TH CIR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-4023
Practice Address - Country:US
Practice Address - Phone:402-680-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-22
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable