Provider Demographics
NPI:1124390729
Name:DRAKE, DIANA (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:GORDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 395
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-3111
Mailing Address - Fax:612-626-0665
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-273-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR100675-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR100675-7OtherRN LICENSING BOARD