Basic Information
| Provider Information | |||||||||
| NPI: | 1306228184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETERLEN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | CPNP-CP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 NAVARRE PL STE 5550 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746472550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2015 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 71005525A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000945331 | 01 | IN | BCBS BMG PEDIATRICS BRISTOL | OTHER | 201307050 | 05 | IN | MEDICAID |