Provider Demographics
NPI:1306118799
Name:DIERKHISING, ELLIE V (IDMT)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:V
Last Name:DIERKHISING
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:V
Other - Last Name:OSTENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDMT
Mailing Address - Street 1:4526 CANDLEWOOD PL APT 201
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0196
Mailing Address - Country:US
Mailing Address - Phone:218-820-8674
Mailing Address - Fax:
Practice Address - Street 1:4526 CANDLEWOOD PL APT 201
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-0196
Practice Address - Country:US
Practice Address - Phone:218-820-8674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians