Provider Demographics
NPI:1568788677
Name:MADSEN, DIANE M (CRMA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:MADSEN
Suffix:
Gender:F
Credentials:CRMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 E PRESTWICK RD
Mailing Address - Street 2:
Mailing Address - City:WINONA LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46590-8910
Mailing Address - Country:US
Mailing Address - Phone:620-805-9113
Mailing Address - Fax:
Practice Address - Street 1:401 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5679
Practice Address - Country:US
Practice Address - Phone:620-272-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTMP140632367500000X
NM76659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered