Provider Demographics
NPI:1790945053
Name:KERKMAN, DIANE M (LPN)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:KERKMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W63 N14264 WASHINGTON AVE #13
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012
Mailing Address - Country:US
Mailing Address - Phone:262-377-3516
Mailing Address - Fax:
Practice Address - Street 1:W63 N14264 WASHINGTON AVE #13
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012
Practice Address - Country:US
Practice Address - Phone:262-377-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33888031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35060300Medicaid