=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770043150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY JUNE DIEMER DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2019
-----------------------------------------------------
Last Update Date | 11/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23450 VIA COCONUT PT
-----------------------------------------------------
City | ESTERO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-343-9696
-----------------------------------------------------
Fax | 239-343-4198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2147
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33902-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-343-9696
-----------------------------------------------------
Fax | 239-343-4198
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | OS20212
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------