Provider Demographics
NPI:1790015543
Name:DORN, DIANE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DORN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5542 N FOX RD
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-9463
Mailing Address - Country:US
Mailing Address - Phone:608-756-9591
Mailing Address - Fax:
Practice Address - Street 1:5542 N FOX RD
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-9463
Practice Address - Country:US
Practice Address - Phone:608-756-9591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI97249-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse