Healthcare Provider Details

I. General information

NPI: 1629323852
Provider Name (Legal Business Name): MARY KATHERINE DIETHRICH R. N. C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 SEVERN DR
RENO NV
89503-2246
US

IV. Provider business mailing address

2070 SEVERN DR
RENO NV
89503-2246
US

V. Phone/Fax

Practice location:
  • Phone: 775-843-6529
  • Fax:
Mailing address:
  • Phone: 775-843-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN19458
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: