Basic Information
| Provider Information | |||||||||
| NPI: | 1578024824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETRICH | ||||||||
| FirstName: | CECILE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1970 ROANOKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241536404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409822463 | ||||||||
| FaxNumber: | 5408553452 | ||||||||
| Practice Location | |||||||||
| Address1: | 1970 ROANOKE BLVD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241536404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403922494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 0024177453 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.