Provider Demographics
NPI:1417165473
Name:FEDEWA, DIANA MARSHALL (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARSHALL
Last Name:FEDEWA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1621
Mailing Address - Country:US
Mailing Address - Phone:608-254-4731
Mailing Address - Fax:608-253-9257
Practice Address - Street 1:719 VINE ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1621
Practice Address - Country:US
Practice Address - Phone:608-254-4731
Practice Address - Fax:608-253-9257
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3058111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI350037758OtherRAILROAD MEDICARE
WI350037758OtherRAILROAD MEDICARE
WI000070644Medicare ID - Type Unspecified