Provider Demographics
NPI:1093303240
Name:DIETZEL, JANE ELLEN
Entity Type:Individual
Prefix:
First Name:JANE ELLEN
Middle Name:
Last Name:DIETZEL
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 1:12766 N OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2321
Mailing Address - Country:US
Mailing Address - Phone:909-702-8704
Mailing Address - Fax:
Practice Address - Street 1:12766 N OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2321
Practice Address - Country:US
Practice Address - Phone:909-702-8704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301446363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care