Provider Demographics
NPI:1699432021
Name:DIETRICH, HAYLEE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:HAYLEE
Middle Name:NICOLE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 NE 1ST AVE APT 904
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-3650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14952 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1213
Practice Address - Country:US
Practice Address - Phone:813-943-9608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1181596OtherNCCPA
FLPA9114069OtherFLORIDA PHYSICIAN ASSISTANT LICENSE