| National Provider Identifier [NPI]: | 1740522101 |
| Last Name Of The Provider | LIETZ |
| First Name Of The Provider | DIANE |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | APRN FNP-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 800 W STATE ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | JACKSONVILLE |
| Zip Code Of The Provider | 626502290 |
| State Code Of The Provider | IL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 9 |
| Number Of Services | 70 |
| Number Of Medicare Beneficiaries | 62 |
| Total Submitted Charge Amount | 4406 |
| Total Medicare Allowed Amount | 1309.75 |
| Total Medicare Payment Amount | 778.34 |
| Total Medicare Standardized Payment Amount | 1179.9 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 9 |
| Number Of Medical Services | 70 |
| Number Of Medicare Beneficiaries With Medical Services | 62 |
| Total Medical Submitted Charge Amount | 4406 |
| Total Medical Medicare Allowed Amount | 1309.75 |
| Total Medical Medicare Payment Amount | 778.34 |
| Total Medical Medicare Standardized Payment Amount | 1179.9 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 24 |
| Number Of Beneficiaries Age 75 to 84 | 16 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 48 |
| Number Of Male Beneficiaries | 14 |
| Number Of Non Hispanic White Beneficiaries | 62 |
| Number Of Black or African American Beneficiaries | 0 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 49 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 13 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 56 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0679 |