Provider Demographics
NPI:1407819477
Name:DIEKMANN, JANENE MARY (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:JANENE
Middle Name:MARY
Last Name:DIEKMANN
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:JANENE
Other - Middle Name:MARY
Other - Last Name:NOLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:620 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-1926
Mailing Address - Country:US
Mailing Address - Phone:573-265-0448
Mailing Address - Fax:573-265-0449
Practice Address - Street 1:5520 STATE ROAD 64
Practice Address - Street 2:BRADENTON CBOC
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:573-265-0448
Practice Address - Fax:573-265-0449
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107141363LA2200X
MO137819363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1407819477Medicaid