Healthcare Provider Details

I. General information

NPI: 1124088406
Provider Name (Legal Business Name): MARLENE DIETRICH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE. 460
VANCOUVER WA
98664-1989
US

IV. Provider business mailing address

505 NE 87TH AVE STE. 460
VANCOUVER WA
98664-1989
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-7771
  • Fax: 360-514-7769
Mailing address:
  • Phone: 360-514-7771
  • Fax: 360-514-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD00035866
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberMD00035866
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: