Provider Demographics
NPI:1982294484
Name:DIEDIKER, SHAYLEE BREANN
Entity type:Individual
Prefix:
First Name:SHAYLEE
Middle Name:BREANN
Last Name:DIEDIKER
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 1:16820 HIGHWAY 146
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:KS
Mailing Address - Zip Code:66733-4185
Mailing Address - Country:US
Mailing Address - Phone:620-605-8860
Mailing Address - Fax:
Practice Address - Street 1:2600 OTTAWA RD
Practice Address - Street 2:
Practice Address - City:NEODESHA
Practice Address - State:KS
Practice Address - Zip Code:66757-1897
Practice Address - Country:US
Practice Address - Phone:620-325-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03630225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant