Provider Demographics
NPI:1427356336
Name:DIEFENDORF, LISSA J (APN)
Entity Type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:J
Last Name:DIEFENDORF
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 W CORRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2803
Mailing Address - Country:US
Mailing Address - Phone:309-222-5736
Mailing Address - Fax:
Practice Address - Street 1:403 W CORRINGTON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2803
Practice Address - Country:US
Practice Address - Phone:309-222-5736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008169364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health