Basic Information
| Provider Information | |||||||||
| NPI: | 1033768148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETRICH | ||||||||
| FirstName: | EMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2137 EAST AVE APT M | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146102643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852452516 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14014 ROUTE 31 WEST | ||||||||
| Address2: | |||||||||
| City: | ALBION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855897066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.