Provider Demographics
NPI:1770043150
Name:DIEMER, KELSEY JUNE (DO)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:JUNE
Last Name:DIEMER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24040 S TAMIAMI TRL STE 202
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24040 S TAMIAMI TRL STE 202
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7040
Practice Address - Country:US
Practice Address - Phone:239-624-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS20212207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine