Provider Demographics
NPI:1093491672
Name:DIETZ, TESSA VIOLA
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:VIOLA
Last Name:DIETZ
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 1:7712 RANNELLS AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-1806
Mailing Address - Country:US
Mailing Address - Phone:314-537-3402
Mailing Address - Fax:
Practice Address - Street 1:7712 RANNELLS AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-1806
Practice Address - Country:US
Practice Address - Phone:314-537-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program