Provider Demographics
NPI:1417125469
Name:DIETTERLE, DIANE MUNYON (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MUNYON
Last Name:DIETTERLE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34012 EL CONTENTO DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2666
Mailing Address - Country:US
Mailing Address - Phone:949-525-8795
Mailing Address - Fax:949-489-0264
Practice Address - Street 1:34012 EL CONTENTO DR
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2666
Practice Address - Country:US
Practice Address - Phone:949-525-8795
Practice Address - Fax:949-489-0264
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA199901163W00000X
CA11140363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR108971OtherMEDICARE NUMBER: INACTIVE
ORS95183OtherUPIN