Provider Demographics
NPI:1407807563
Name:VANDERLIN, DIANE LYNN (RN MSN APNP C)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:LYNN
Last Name:VANDERLIN
Suffix:
Gender:F
Credentials:RN MSN APNP C
Other - Prefix:
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Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:725 S WEBSTER AVE STE 303
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3539
Practice Address - Country:US
Practice Address - Phone:920-431-5650
Practice Address - Fax:920-433-7400
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704152987363LF0000X
WI1309-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43830900Medicaid
0240937OtherAMERICAN NURSES CREDENTIALING CENTER
S52483Medicare UPIN
WI43830900Medicaid