Healthcare Provider Details

I. General information

NPI: 1750438826
Provider Name (Legal Business Name): NICOLE DAWN DIEDRICH P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MAIN ST
PECATONICA IL
61063-9195
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 815-239-2233
  • Fax: 815-239-9999
Mailing address:
  • Phone: 630-590-4046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number070013314
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013314
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: