Individual
BONITA G. DIETRICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2900 N KNOXVILLE AVE, PEORIA, IL 61603-1748
(309) 688-3616
(309) 687-3370
Mailing address
2900 N KNOXVILLE AVE, PEORIA, IL 61603-1748
(309) 688-3616
(309) 687-3370
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
041248649/209000680
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
809840019
MEDICARE INDIVIDUAL PTAN
IL
01
—
CA4079
RR GROUP #
—
Enumeration date
10/15/2006
Last updated
08/05/2009
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