MEDICARE: DIETERMAN KLINIK, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1386414431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIETERMAN KLINIK, LLC

Provider Business Mailing Address
First Line	:	4200 SOMERSET DR STE 208
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-5244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6208 FALL HARVEST WAY
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-7242
Country	:	US
Telephone Number	:	816-695-2433
Fax Number	:

Authorized Official
Title or Position	:	DNP
Name	:	DR. LAUREN ABIGAIL DIETERMAN
Credential	:	DNP, FNP-C, BSN
Telephone Number	:	816-695-2433

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	01/08/2024

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