Healthcare Provider Details

I. General information

NPI: 1548368657
Provider Name (Legal Business Name): KARI NICOLE DIEDERICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARI NICOLE RICKMAN CRNA

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WELLNESS DR
MIDLAND MI
48670-0001
US

IV. Provider business mailing address

4502 JAMES DR
MIDLAND MI
48642-3782
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-3000
  • Fax:
Mailing address:
  • Phone: 989-600-3236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704215629
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: