Provider Demographics
NPI:1750438826
Name:DIEDRICH, NICOLE DAWN (PT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DAWN
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN
Mailing Address - Street 2:STE 600C
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-590-4046
Mailing Address - Fax:
Practice Address - Street 1:219 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECATONICA
Practice Address - State:IL
Practice Address - Zip Code:61063-9195
Practice Address - Country:US
Practice Address - Phone:815-239-2233
Practice Address - Fax:815-239-9999
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013314174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16007Medicare ID - Type Unspecified