Provider Demographics
NPI:1255484952
Name:LUEDTKE, DIANE B (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:B
Last Name:LUEDTKE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WHITE LN
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-1022
Mailing Address - Country:US
Mailing Address - Phone:570-325-4170
Mailing Address - Fax:570-325-8336
Practice Address - Street 1:211 N 12TH ST
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-1138
Practice Address - Country:US
Practice Address - Phone:570-401-3960
Practice Address - Fax:570-325-8336
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006236C363LA2200X
PATP006235H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology