Provider Demographics
NPI:1952482705
Name:O'DONNELL, DIANE M (APNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1220 DEWEY AVENUE
Mailing Address - Street 2:LORTON BUILDING
Mailing Address - City:WAUWAUTOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-257-7356
Mailing Address - Fax:414-257-7515
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:LORTON BUILDING
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2504
Practice Address - Country:US
Practice Address - Phone:414-257-7356
Practice Address - Fax:414-257-7515
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1020-033363L00000X
WI74350363LP0808X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014190Medicaid
WI439-167-00Medicaid
WI439-167-00Medicaid
WIMO1323687OtherDEA REGISTRATION