Provider Demographics
NPI:1457134678
Name:DICIOLLA, ERIN LEE (RN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:LEE
Last Name:DICIOLLA
Suffix:
Gender:
Credentials:RN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:LEE
Other - Last Name:TELANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7311
Mailing Address - Country:US
Mailing Address - Phone:417-322-6622
Mailing Address - Fax:417-350-1935
Practice Address - Street 1:3600 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7311
Practice Address - Country:US
Practice Address - Phone:417-322-6622
Practice Address - Fax:417-350-1935
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR51586363LP0808X
MO2024030370363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR334022758Medicaid
MO420145421Medicaid