Basic Information
| Provider Information | |||||||||
| NPI: | 1477941938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETZ | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21333 HAGGERTY RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486620250 | ||||||||
| FaxNumber: | 2486629845 | ||||||||
| Practice Location | |||||||||
| Address1: | 3523 WICKENHAUSER AVE | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184658887 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2015 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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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 | 209.011378 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.