Provider Demographics
NPI:1548368657
Name:DIEDERICH, KARI NICOLE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KARI
Middle Name:NICOLE
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KARI
Other - Middle Name:NICOLE
Other - Last Name:RICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4502 JAMES DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-3782
Mailing Address - Country:US
Mailing Address - Phone:989-600-3236
Mailing Address - Fax:
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-0001
Practice Address - Country:US
Practice Address - Phone:989-839-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215629367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered