Provider Demographics
NPI:1144892589
Name:DIERDORF, MARJORIE
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:DIERDORF
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 1:295 DENTON DR
Mailing Address - Street 2:
Mailing Address - City:YOE
Mailing Address - State:PA
Mailing Address - Zip Code:17313-1422
Mailing Address - Country:US
Mailing Address - Phone:321-514-1366
Mailing Address - Fax:
Practice Address - Street 1:1550 RODNEY RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-9715
Practice Address - Country:US
Practice Address - Phone:717-846-8791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PASP024514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program