Provider Demographics
NPI:1902038144
Name:DIENELL, KATIE MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:MARIE
Last Name:DIENELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 NW 170TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5521
Mailing Address - Country:US
Mailing Address - Phone:314-362-9123
Mailing Address - Fax:
Practice Address - Street 1:160 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5521
Practice Address - Country:US
Practice Address - Phone:305-651-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117206363A00000X
MO2016044080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS
1124347OtherNCCPA