Provider Demographics
NPI:1508517491
Name:PIESCHL, IDA RAE
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:RAE
Last Name:PIESCHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 STATE ST APT E2
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5700
Mailing Address - Country:US
Mailing Address - Phone:785-845-3753
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE HL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1257
Practice Address - Country:US
Practice Address - Phone:785-845-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program