Provider Demographics
NPI:1548628878
Name:TIETJEN, LOIS
Entity type:Individual
Prefix:MS
First Name:LOIS
Middle Name:
Last Name:TIETJEN
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 1:143 EAGLE HILL CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1609
Mailing Address - Country:US
Mailing Address - Phone:631-504-6460
Mailing Address - Fax:
Practice Address - Street 1:35 LONGWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2045
Practice Address - Country:US
Practice Address - Phone:631-924-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator