=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609303379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL DENISE DIERKS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9947 W HAPPY VALLEY RD STE 104
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-434-5748
-----------------------------------------------------
Fax | 623-566-9665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2405 ROCK ISLAND RD
-----------------------------------------------------
City | OELWEIN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50662-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-283-2651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | TAP10109
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------