Basic Information
| Provider Information | |||||||||
| NPI: | 1326617903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIEDE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 617 E RIVERSIDE DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847908720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018157402 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 617 E RIVERSIDE DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847908720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356888866 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2021 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 12254287-4101 | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.