Provider Demographics
NPI:1366578981
Name:DIEDALIS, KATHLEEN (CST/CSFA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DIEDALIS
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:893 MENDES CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-3506
Mailing Address - Country:US
Mailing Address - Phone:614-824-5200
Mailing Address - Fax:888-329-6432
Practice Address - Street 1:893 MENDES CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-3506
Practice Address - Country:US
Practice Address - Phone:614-824-5200
Practice Address - Fax:888-329-6432
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant