Healthcare Provider Details

I. General information

NPI: 1104249093
Provider Name (Legal Business Name): MICHELE DEITERICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 MARTIN AVE
EPHRATA PA
17522-1724
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-733-0311
  • Fax: 717-721-5861
Mailing address:
  • Phone: 717-851-1405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN296687L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: