Provider Demographics
NPI:1881676534
Name:BERKEY, DIANE M (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:BERKEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2034
Mailing Address - Country:US
Mailing Address - Phone:641-424-6704
Mailing Address - Fax:641-424-6709
Practice Address - Street 1:1410 6TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-4818
Practice Address - Country:US
Practice Address - Phone:641-424-6704
Practice Address - Fax:641-424-6709
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061074367500000X
IAD061074367500000X
IL045177367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1881676534Medicaid
IA1881676534Medicare PIN