Provider Demographics
NPI:1104068279
Name:DIETERLE, LYNNE FRANCES (PA)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:FRANCES
Last Name:DIETERLE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:43455 SCHOENHERR RD
Mailing Address - Street 2:STE 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1972
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:586-726-8365
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2022-07-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP3235002Medicare PIN