Provider Demographics
NPI:1679267215
Name:DIECKMAN, MARY A (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DIECKMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LEAF LN
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9549
Mailing Address - Country:US
Mailing Address - Phone:160-131-6803
Mailing Address - Fax:
Practice Address - Street 1:2301 LUCIEN WAY STE 325
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7020
Practice Address - Country:US
Practice Address - Phone:888-300-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS896088163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency