Provider Demographics
NPI:1508230509
Name:SCHMIDT, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-3406
Mailing Address - Country:US
Mailing Address - Phone:920-205-4236
Mailing Address - Fax:
Practice Address - Street 1:354 ELM ST
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-3406
Practice Address - Country:US
Practice Address - Phone:920-205-4236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-14
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI112122-03163W00000X
WI112122163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse