Provider Demographics
NPI:1124088406
Name:DIETRICH, MARLENE (MD)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 NE 87TH AVE
Mailing Address - Street 2:STE. 460
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1989
Mailing Address - Country:US
Mailing Address - Phone:360-514-7771
Mailing Address - Fax:360-514-7769
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:STE. 460
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-514-7771
Practice Address - Fax:360-514-7769
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000358662084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8222481Medicaid
WA8222481Medicaid
130020651Medicare PIN
WAG8885629Medicare PIN