Provider Demographics
NPI:1841975752
Name:DIETZEL, ERIN COLLEEN (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:COLLEEN
Last Name:DIETZEL
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GRANNY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2879
Mailing Address - Country:US
Mailing Address - Phone:631-666-1234
Mailing Address - Fax:
Practice Address - Street 1:100 GRANNY RD STE 1
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2879
Practice Address - Country:US
Practice Address - Phone:631-666-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY603656163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)