Provider Demographics
NPI:1083104046
Name:FIELDS, DIEDRA
Entity Type:Individual
Prefix:
First Name:DIEDRA
Middle Name:
Last Name:FIELDS
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 1:12318 BOYDTON PLANK RD
Mailing Address - Street 2:
Mailing Address - City:DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23841-2454
Mailing Address - Country:US
Mailing Address - Phone:434-774-5968
Mailing Address - Fax:
Practice Address - Street 1:12318 BOYDTON PLANK RD
Practice Address - Street 2:
Practice Address - City:DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23841-2454
Practice Address - Country:US
Practice Address - Phone:434-774-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician