Basic Information
| Provider Information | |||||||||
| NPI: | 1174754477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEDRICH | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
| FaxNumber: | 6238766965 | ||||||||
| Practice Location | |||||||||
| Address1: | 9165 W THUNDERBIRD RD, | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235836554 | ||||||||
| FaxNumber: | 6235236581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2009 | ||||||||
| LastUpdateDate: | 11/20/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP3288 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AP3288 | 01 | AZ | AZ MEDICAL LICENSE | OTHER | 449581 | 05 | AZ | MEDICAID |