Provider Demographics
NPI:1730780479
Name:TIETJE, MAE LYNNE (MSN, RN, APN, AGNP-C)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:LYNNE
Last Name:TIETJE
Suffix:
Gender:F
Credentials:MSN, RN, APN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-4924
Mailing Address - Country:US
Mailing Address - Phone:609-204-6792
Mailing Address - Fax:
Practice Address - Street 1:3830 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6080
Practice Address - Country:US
Practice Address - Phone:609-345-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01069800363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care