Provider Demographics
NPI:1780568055
Name:DIETRICH, AMANDA RENEE (CNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:NEW MELLE
Mailing Address - State:MO
Mailing Address - Zip Code:63365-0025
Mailing Address - Country:US
Mailing Address - Phone:636-463-3277
Mailing Address - Fax:
Practice Address - Street 1:905 HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-2431
Practice Address - Country:US
Practice Address - Phone:573-324-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025028303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily