Provider Demographics
NPI:1891194205
Name:DIEKMAN, LAURA SUSAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSAN
Last Name:DIEKMAN
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2572 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9356
Practice Address - Country:US
Practice Address - Phone:941-429-3545
Practice Address - Fax:941-429-3546
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9287102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLECCRROtherBCBS
FL021158400Medicaid
FLIF763XOtherMEDICARE