Provider Demographics
NPI:1043665193
Name:DIETRICH, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 CLAYTON ST APT 202
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-2463
Mailing Address - Country:US
Mailing Address - Phone:720-934-7241
Mailing Address - Fax:
Practice Address - Street 1:1362 CLAYTON ST APT 202
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-2463
Practice Address - Country:US
Practice Address - Phone:720-934-7241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO191016163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical