Provider Demographics
NPI:1689600264
Name:DIETERICH, MAUREEN L (NP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:L
Last Name:DIETERICH
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:PO BOX 7028
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4674 SNOW MESA DR
Practice Address - Street 2:STE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-8615
Practice Address - Country:US
Practice Address - Phone:970-482-3712
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO58247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801325Medicare ID - Type Unspecified
COP26762Medicare UPIN
COP00267882Medicare ID - Type UnspecifiedRAILROAD