Provider Demographics
NPI:1497704100
Name:OMTVEDT, DIANE JEAN (NP AND LAC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:JEAN
Last Name:OMTVEDT
Suffix:
Gender:F
Credentials:NP AND LAC
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:JEAN
Other - Last Name:OMTVEDT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP AND LAC
Mailing Address - Street 1:5310 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-9670
Mailing Address - Country:US
Mailing Address - Phone:715-832-1888
Mailing Address - Fax:
Practice Address - Street 1:1227 MENOMONIE ST
Practice Address - Street 2:C
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5996
Practice Address - Country:US
Practice Address - Phone:715-836-9696
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67733-030163W00000X
WI233-055171100000X
WI671-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner