Provider Demographics
NPI:1629856257
Name:DIECKMAN, MELODY (PA-C)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:DIECKMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86-6 FERNE BLVD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-5464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 JOLLY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2324
Practice Address - Country:US
Practice Address - Phone:610-272-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
PAOA006810363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical