Provider Demographics
NPI:1538856984
Name:TIEDEMAN, KANISHA LANAE (DOULA)
Entity type:Individual
Prefix:MRS
First Name:KANISHA
Middle Name:LANAE
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1275
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-1275
Mailing Address - Country:US
Mailing Address - Phone:907-235-9642
Mailing Address - Fax:
Practice Address - Street 1:6 MILE HARTNEY BAY ROAD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574-1275
Practice Address - Country:US
Practice Address - Phone:907-235-9642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula