Provider Demographics
NPI:1922714674
Name:DIETRICH, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:DIETRICH
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 1:22850 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:GOBLES
Mailing Address - State:MI
Mailing Address - Zip Code:49055-9111
Mailing Address - Country:US
Mailing Address - Phone:734-260-3806
Mailing Address - Fax:
Practice Address - Street 1:805 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2854
Practice Address - Country:US
Practice Address - Phone:269-286-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704324392363LA2100X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health