Provider Demographics
NPI:1639660533
Name:DIETERICH, KELSY (CST/CSFA)
Entity type:Individual
Prefix:
First Name:KELSY
Middle Name:
Last Name:DIETERICH
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 FRANKLIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6922
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:5100 FRANKLIN AVE STE C
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6922
Practice Address - Country:US
Practice Address - Phone:254-754-0375
Practice Address - Fax:254-754-2667
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX178624246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist