Healthcare Provider Details

I. General information

NPI: 1144379470
Provider Name (Legal Business Name): CAROLYN ELAINE DIEDRICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E HWY 90
HONDO TX
78861
US

IV. Provider business mailing address

819 WATER ST SUITE 300
KERRVILLE TX
78028-5333
US

V. Phone/Fax

Practice location:
  • Phone: 830-426-4362
  • Fax: 830-426-4366
Mailing address:
  • Phone: 830-792-3300
  • Fax: 830-792-5771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number522431
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: