Healthcare Provider Details

I. General information

NPI: 1770126104
Provider Name (Legal Business Name): ASHLEY KAY DIETSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 02/28/2024
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 ILLINI DR
SILVIS IL
61282-2907
US

IV. Provider business mailing address

855 ILLINI DR STE 408
SILVIS IL
61282-2904
US

V. Phone/Fax

Practice location:
  • Phone: 309-281-2140
  • Fax:
Mailing address:
  • Phone: 309-281-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA156723
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: