Basic Information
Provider Information | |||||||||
NPI: | 1619525219 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIETZ | ||||||||
FirstName: | DEANNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DR STE 1200W | ||||||||
Address2: |   | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750014624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25733 RYE CANYON RD | ||||||||
Address2: |   | ||||||||
City: | VALENCIA | ||||||||
State: | CA | ||||||||
PostalCode: | 913551135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669446046 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2019 | ||||||||
LastUpdateDate: | 10/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9373263 | FL | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | R48116 | ND | Y |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 397978 | OH | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 95067001 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | R238938 | MD | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.