Provider Demographics
NPI:1720309768
Name:DIECKMANN, KRISTI KAY (DC, MS)
Entity Type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:KAY
Last Name:DIECKMANN
Suffix:
Gender:F
Credentials:DC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 PARAGON DR
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1773
Mailing Address - Country:US
Mailing Address - Phone:618-973-5522
Mailing Address - Fax:
Practice Address - Street 1:1210 PARAGON DR
Practice Address - Street 2:SUITE 1B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1773
Practice Address - Country:US
Practice Address - Phone:618-973-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011634111NR0400X
MO2010003872111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation