Basic Information
Provider Information | |||||||||
NPI: | 1700839214 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIETRICH | ||||||||
FirstName: | SHELLI | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11225 | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374012225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238925602 | ||||||||
FaxNumber: | 4238925838 | ||||||||
Practice Location | |||||||||
Address1: | 975 E THIRD ST | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374032147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237787608 | ||||||||
FaxNumber: | 4237782360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2006 | ||||||||
LastUpdateDate: | 01/20/2010 | ||||||||
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 | RN96460 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | APN11855 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 8053127 | 05 | NC |   | MEDICAID | 236720150A | 05 | GA |   | MEDICAID | 4117699 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | N355280 | 01 | GA | WELLCARE (GA MEDICAID) | OTHER | 3636453 | 05 | TN |   | MEDICAID | P00316932 | 01 | TN | RAILROAD MEDICARE | OTHER |