Healthcare Provider Details

I. General information

NPI: 1194958330
Provider Name (Legal Business Name): JULIE L DIETERMAN RN, CNOR, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 VISA DR STE 1
NORMAL IL
61761-2195
US

IV. Provider business mailing address

1604 VISA DR STE 1
NORMAL IL
61761-2195
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-4716
  • Fax:
Mailing address:
  • Phone: 309-846-4716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041.263681
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: