MEDICARE: KELLY ANN DIEKEMPER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	242.002236	IL
2	235Z00000X	Speech-Language Pathologist	146.011505	IL

General Provider Information

NPI Number	:	1285992560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN DIEKEMPER

Provider Business Mailing Address
First Line	:	740 N HARRISON ST
Second Line	:
City	:	TRENTON
State	:	IL
Zip	:	62293-1072
Country	:	US
Telephone Number	:	618-444-2984
Fax Number	:

Provider Business Practice Location Address
First Line	:	634 N MAIN ST STE 3
Second Line	:
City	:	O FALLON
State	:	IL
Zip	:	62269-3746
Country	:	US
Telephone Number	:	618-632-4222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	03/18/2013

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Directions to “ KELLY ANN DIEKEMPER ” Practice Location

Language	Start Address	Practice Location

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