Basic Information
| Provider Information | |||||||||
| NPI: | 1912316506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIERKSEN | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | FELICIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1823 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1823 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665023381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857763322 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2014 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1649 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.