Provider Demographics
NPI:1700945508
Name:DIETRICH, TIFFANY LEE (LM)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:LEE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 S HIGUERA ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7700
Mailing Address - Country:US
Mailing Address - Phone:805-548-0606
Mailing Address - Fax:805-856-1521
Practice Address - Street 1:6024 MAGAZINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5824
Practice Address - Country:US
Practice Address - Phone:504-459-2426
Practice Address - Fax:504-285-2226
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM 252176B00000X
CAND 410175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALM 252OtherLICENSE NUMBER
LA324935OtherLICENSE NUMBER