Provider Demographics
NPI:1093907453
Name:MRKVICKA, DIANE AGNES (RN)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:AGNES
Last Name:MRKVICKA
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:PO BOX 2280
Mailing Address - Street 2:360 PEAK ONE DRIVE SUITE 230
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-2280
Mailing Address - Country:US
Mailing Address - Phone:970-668-9195
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DRIVE
Practice Address - Street 2:SUITE 230
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO74772163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80582834Medicaid