Provider Demographics
NPI:1376747261
Name:DIETRICH, CHRISTINE MARIE (APRN, GNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:APRN, GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W UPHAM ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1483
Mailing Address - Country:US
Mailing Address - Phone:715-301-7270
Mailing Address - Fax:715-384-8046
Practice Address - Street 1:303 W UPHAM ST STE 200
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1483
Practice Address - Country:US
Practice Address - Phone:715-204-8555
Practice Address - Fax:715-384-8046
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR200410-1363LG0600X
WI2004-33363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI004881926OtherMEDICARE PIN
MN1376747261Medicaid
WI1376747261Medicaid
WI1376747261Medicaid