Provider Demographics
NPI:1790283596
Name:MIKULENCAK-PICHA, DIANA MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:MIKULENCAK-PICHA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 N AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-6220
Mailing Address - Country:US
Mailing Address - Phone:361-401-1344
Mailing Address - Fax:
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX830443163W00000X
TXAP136271363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse