Provider Demographics
NPI:1346345717
Name:DIERICH, MARY THERESE (GNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:DIERICH
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
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Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 381
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-624-9499
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:3-150 PWB, CLINIC 3A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-624-9499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR 094653-3363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS45397Medicare UPIN