Provider Demographics
NPI:1508410747
Name:DIEDRICH, CLORISSA (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:CLORISSA
Middle Name:
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 N CENTER AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1684
Mailing Address - Country:US
Mailing Address - Phone:517-240-3211
Mailing Address - Fax:
Practice Address - Street 1:829 N CENTER AVE STE 130
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1684
Practice Address - Country:US
Practice Address - Phone:989-731-7930
Practice Address - Fax:989-731-7948
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704321562363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics