MEDICARE: MS. KRYSTAL DAWN DIETRICH

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	363LF0000X	Family Nurse Practitioner	APRN.CNP.023735	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN.337952	OTHER	OH	RN LICENSE

General Provider Information

NPI Number	:	1841784089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRYSTAL DAWN DIETRICH

Provider Business Mailing Address
First Line	:	PO BOX 636930
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-0930
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 W HIGH ST STE 240
Second Line	:
City	:	LIMA
State	:	OH
Zip	:	45801-3959
Country	:	US
Telephone Number	:	419-996-5037
Fax Number	:	419-996-5068

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

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	04/06/2026

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