Provider Demographics
NPI:1265766752
Name:DWYER, DARICE DIANE (PHN)
Entity type:Individual
Prefix:
First Name:DARICE
Middle Name:DIANE
Last Name:DWYER
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 AMERICA AVE NW
Mailing Address - Street 2:SUITE #130
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3818
Mailing Address - Country:US
Mailing Address - Phone:218-333-8152
Mailing Address - Fax:218-333-8160
Practice Address - Street 1:616 AMERICA AVE NW
Practice Address - Street 2:SUITE #130
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3818
Practice Address - Country:US
Practice Address - Phone:218-333-8152
Practice Address - Fax:218-333-8160
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR091398-0163WC1500X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8231BEOtherBLUE CROSS BLUE SHIELD
MN567553700OtherPRIME WEST