Provider Demographics
NPI:1659492742
Name:DIEDIKER, NINA G (OTR)
Entity type:Individual
Prefix:MRS
First Name:NINA
Middle Name:G
Last Name:DIEDIKER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24408 W 391ST ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:KS
Mailing Address - Zip Code:66026-7743
Mailing Address - Country:US
Mailing Address - Phone:913-849-3598
Mailing Address - Fax:913-755-3854
Practice Address - Street 1:1615 PARKER AVE
Practice Address - Street 2:
Practice Address - City:OSAWATOMIE
Practice Address - State:KS
Practice Address - Zip Code:66064-1703
Practice Address - Country:US
Practice Address - Phone:913-755-4165
Practice Address - Fax:913-755-3854
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-00873225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-00873OtherLICENSE