Provider Demographics
NPI:1386748911
Name:DIEDRICH, ASHLEY L (AA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:L
Last Name:DIEDRICH
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:L
Other - Last Name:LEITERITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3605
Practice Address - Fax:920-433-3589
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
748OtherNATIONAL COMMISSION CERTIFICATION ANESTHESIA ASSISTANTS