Basic Information
| Provider Information | |||||||||
| NPI: | 1225395999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIEDEKEN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | DOYLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 APPLIED BANK BLVD STE 11 | ||||||||
| Address2: | NEMOURS DUPONT PEDIATRICS, GLEN MILLS URGENT CARE | ||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193423501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848008630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD454113 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.