Provider Demographics
NPI:1336469550
Name:DIETZ, REBECCA J (APRN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:J
Last Name:DIETZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:J
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EMILE AT 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-2027
Practice Address - Country:US
Practice Address - Phone:402-559-8888
Practice Address - Fax:402-559-3060
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA139805363L00000X
NE111098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098684515OtherMEDICARE PTAN