Provider Demographics
NPI:1386734689
Name:DIETRICH, BONITA G
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:G
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-1748
Mailing Address - Country:US
Mailing Address - Phone:309-688-3616
Mailing Address - Fax:309-687-3370
Practice Address - Street 1:2900 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-1748
Practice Address - Country:US
Practice Address - Phone:309-688-3616
Practice Address - Fax:309-687-3370
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041248649/209000680363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840019OtherMEDICARE INDIVIDUAL PTAN
CA4079OtherRR GROUP #
IL500005925 / CN1588Medicare ID - Type UnspecifiedRR
ILK36994Medicare ID - Type UnspecifiedINDIVIDUAL # EFF 5-20-07
IL504850Medicare ID - Type UnspecifiedINDIVIDUAL #
IL809840019OtherMEDICARE INDIVIDUAL PTAN
IL500005925Medicare ID - Type UnspecifiedRR INDIVIDUAL
CA4079OtherRR GROUP #
S67340Medicare UPIN