Provider Demographics
NPI:1932236346
Name:DIEDRICH, KRISTINE MEGAN (RN)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MEGAN
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 VALEJO CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-2275
Mailing Address - Country:US
Mailing Address - Phone:719-210-6784
Mailing Address - Fax:
Practice Address - Street 1:301 S UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3123
Practice Address - Country:US
Practice Address - Phone:719-578-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO165350163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80020551Medicaid