Provider Demographics
NPI:1174754477
Name:DIEDRICH, ELIZABETH ANNE (FNP)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-876-6965
Practice Address - Street 1:9165 W THUNDERBIRD RD,
Practice Address - Street 2:STE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4669
Practice Address - Country:US
Practice Address - Phone:623-583-6554
Practice Address - Fax:623-523-6581
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP3288OtherAZ MEDICAL LICENSE
AZ449581Medicaid
AZZ131995Medicare PIN