1174754477 NPI number — MS. ELIZABETH ANNE DIEDRICH F.N.P.

Table of content: MS. ELIZABETH ANNE DIEDRICH F.N.P. (NPI 1174754477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174754477 NPI number — MS. ELIZABETH ANNE DIEDRICH F.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIEDRICH
Provider First Name:
ELIZABETH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
F.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174754477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13640 N PLAZA DEL RIO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-4846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-876-3800
Provider Business Mailing Address Fax Number:
623-876-6965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9165 W THUNDERBIRD RD,
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-4669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-583-6554
Provider Business Practice Location Address Fax Number:
623-523-6581
Provider Enumeration Date:
08/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP3288 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AP3288 . This is a "AZ MEDICAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 449581 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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