Healthcare Provider Details

I. General information

NPI: 1043989106
Provider Name (Legal Business Name): HEIDI DITTRICH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-7500
  • Fax: 707-559-7620
Mailing address:
  • Phone: 707-559-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95203765
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: