Provider Demographics
NPI:1225226483
Name:MEDINA, DIANE M (RN)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:MEDINA
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 1:1664 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1650
Mailing Address - Country:US
Mailing Address - Phone:262-551-2826
Mailing Address - Fax:847-937-7812
Practice Address - Street 1:1664 19TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1650
Practice Address - Country:US
Practice Address - Phone:262-551-2826
Practice Address - Fax:847-937-7812
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6534930163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse