Healthcare Provider Details

I. General information

NPI: 1699951590
Provider Name (Legal Business Name): RETA JOYCE DIEDRICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 4TH ST.
SANDSTONE MN
55072
US

IV. Provider business mailing address

606 POWER AVE S P.O. BOX 684
HINCKLEY MN
55037-9366
US

V. Phone/Fax

Practice location:
  • Phone: 320-245-5362
  • Fax:
Mailing address:
  • Phone: 320-384-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR059996-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: