Provider Demographics
NPI:1417073875
Name:DIETZE, COREY LYNN (DPT, ATC-LAC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:LYNN
Last Name:DIETZE
Suffix:
Gender:M
Credentials:DPT, ATC-LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:650 JOEL DRIVE
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:270-798-8400
Mailing Address - Fax:
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOEL DRIVE
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29738225100000X
VA2305207917225100000X
CO9739225100000X
IA04029225100000X
UT114662251X0800X
IA005152255A2300X
FL42532255A2300X
TN11466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer