Provider Demographics
NPI:1932338282
Name:DIETZ, ELIZABETH GRAY (CPNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRAY
Last Name:DIETZ
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14400 SOMMERVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6835
Mailing Address - Country:US
Mailing Address - Phone:804-737-9543
Mailing Address - Fax:
Practice Address - Street 1:14400 SOMMERVILLE CT
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-6835
Practice Address - Country:US
Practice Address - Phone:804-379-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168311363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner