Provider Demographics
NPI:1497349666
Name:DIETRICH, KIMBERLY KAY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S WHITLOCK ST
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:IN
Mailing Address - Zip Code:46506-1626
Mailing Address - Country:US
Mailing Address - Phone:574-546-0330
Mailing Address - Fax:
Practice Address - Street 1:417 S WHITLOCK ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:IN
Practice Address - Zip Code:46506-1626
Practice Address - Country:US
Practice Address - Phone:574-546-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28238600A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty