1174884100 NPI number — MRS. ADRIENNE KELLY DIETRICH M.S., ED.

Table of content: MRS. ADRIENNE KELLY DIETRICH M.S., ED. (NPI 1174884100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174884100 NPI number — MRS. ADRIENNE KELLY DIETRICH M.S., ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETRICH
Provider First Name:
ADRIENNE
Provider Middle Name:
KELLY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., ED.
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:
1174884100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7289 RICE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13367-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-376-4208
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18564 US ROUTE 11
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-786-7202
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2012

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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