Provider Demographics
NPI:1083014385
Name:DIETHERT, DANETTE LEE (PMHNP)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:LEE
Last Name:DIETHERT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:DANETTE
Other - Middle Name:LEE
Other - Last Name:CHRISTIANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-829-2861
Practice Address - Fax:218-828-3130
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-104601-4363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health