Healthcare Provider Details

I. General information

NPI: 1417695925
Provider Name (Legal Business Name): HANNAH R DIETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6417 W IRVING PARK RD
CHICAGO IL
60634-2437
US

IV. Provider business mailing address

6337 N OAK PARK AVE
CHICAGO IL
60631-2031
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-7112
  • Fax:
Mailing address:
  • Phone: 773-255-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: