Provider Demographics
NPI:1104374727
Name:DIETHRICH, NATHALIE K (PMHNP)
Entity Type:Individual
Prefix:
First Name:NATHALIE
Middle Name:K
Last Name:DIETHRICH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1206
Mailing Address - Country:US
Mailing Address - Phone:217-362-6262
Mailing Address - Fax:217-362-6290
Practice Address - Street 1:151 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523-1206
Practice Address - Country:US
Practice Address - Phone:217-362-6262
Practice Address - Fax:217-362-6290
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL377001689363LP0808X
IL209.014716363LP0808X
IL277001744363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health