1376747261 NPI number — MRS. CHRISTINE MARIE DIETRICH APRN, GNP-BC

Table of content: MRS. CHRISTINE MARIE DIETRICH APRN, GNP-BC (NPI 1376747261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376747261 NPI number — MRS. CHRISTINE MARIE DIETRICH APRN, GNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETRICH
Provider First Name:
CHRISTINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, GNP-BC
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:
1376747261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 W UPHAM ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54449-1483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-301-7270
Provider Business Mailing Address Fax Number:
715-384-8046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 W UPHAM ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54449-1483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-204-8555
Provider Business Practice Location Address Fax Number:
715-384-8046
Provider Enumeration Date:
06/13/2007

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: 363LG0600X , with the licence number:  R200410-1 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 2004-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004881926 . This is a "MEDICARE PIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1376747261 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376747261 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com