Provider Demographics
NPI:1922492974
Name:DIETRICK, DAVID ALAN (APRN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALAN
Last Name:DIETRICK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 WEST ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1075
Mailing Address - Country:US
Mailing Address - Phone:034-571-9662
Mailing Address - Fax:
Practice Address - Street 1:184 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1625
Practice Address - Country:US
Practice Address - Phone:203-688-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004178363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008058287Medicaid