Provider Demographics
NPI:1184207078
Name:DIETZ, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
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 1:472 S STATE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4326
Mailing Address - Country:US
Mailing Address - Phone:918-330-0671
Mailing Address - Fax:
Practice Address - Street 1:472 S STATE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4326
Practice Address - Country:US
Practice Address - Phone:918-330-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist