Provider Demographics
NPI:1760647465
Name:DIETERICH, ALISA MICHELLE (RN MSN FNP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MICHELLE
Last Name:DIETERICH
Suffix:
Gender:F
Credentials:RN MSN FNP
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Mailing Address - Street 1:967 BIG SUR CT
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-4508
Mailing Address - Country:US
Mailing Address - Phone:707-486-2672
Mailing Address - Fax:
Practice Address - Street 1:11333 PROSPECT DRIVE
Practice Address - Street 2:
Practice Address - City:MARTELL
Practice Address - State:CA
Practice Address - Zip Code:95654
Practice Address - Country:US
Practice Address - Phone:209-268-0560
Practice Address - Fax:209-214-6946
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2022-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CANP18158363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner