Provider Demographics
NPI:1225341555
Name:WISNIEWSKI, DIEDRE ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:DIEDRE
Middle Name:ANN
Last Name:WISNIEWSKI
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 1:404 OLD MAIN DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1360
Mailing Address - Country:US
Mailing Address - Phone:304-872-3611
Mailing Address - Fax:304-872-4626
Practice Address - Street 1:400 OLD MAIN DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1360
Practice Address - Country:US
Practice Address - Phone:304-872-3611
Practice Address - Fax:304-872-4626
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64342390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program