Basic Information
| Provider Information | |||||||||
| NPI: | 1720037351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETRICK | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/16/2010 | ||||||||
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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 | 163WP0808X | RN15602 | NV | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 163W00000X | RN15602 | NV | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 100507626 | 05 | NV | MEDICAID |