Provider Demographics
NPI:1548221575
Name:DIERCKS, CONNIE I (CNM)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:I
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 E 26TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1857
Mailing Address - Country:US
Mailing Address - Phone:612-729-3059
Mailing Address - Fax:
Practice Address - Street 1:555 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2209
Practice Address - Country:US
Practice Address - Phone:651-266-1255
Practice Address - Fax:651-266-1350
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNM0216367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN339540500Medicaid
MN339540500Medicaid
MN339540500Medicaid