Provider Demographics
NPI:1467475939
Name:HOLZEM, DIANE P (RN,C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:P
Last Name:HOLZEM
Suffix:
Gender:F
Credentials:RN,C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:A
Other - Last Name:PINARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,C
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:505-759-7233
Mailing Address - Fax:505-759-7294
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-7233
Practice Address - Fax:505-759-7294
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR17040163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM320057Medicare Oscar/Certification