Healthcare Provider Details

I. General information

NPI: 1417955451
Provider Name (Legal Business Name): JEANNENE L DIETER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8312 US HIGHWAY 301 N STE 105
PARRISH FL
34219-8725
US

IV. Provider business mailing address

8312 US HIGHWAY 301 N STE 105
PARRISH FL
34219-8725
US

V. Phone/Fax

Practice location:
  • Phone: 941-776-5770
  • Fax: 941-845-0162
Mailing address:
  • Phone: 941-776-0577
  • Fax: 941-845-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP0002256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: