Provider Demographics
NPI:1417030701
Name:DIETERICH, LESLIE A (CNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:DIETERICH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-6516
Mailing Address - Country:US
Mailing Address - Phone:740-348-1840
Mailing Address - Fax:740-348-1841
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-6516
Practice Address - Country:US
Practice Address - Phone:740-348-1840
Practice Address - Fax:740-348-1841
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-02929-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics