Provider Demographics
NPI:1457583163
Name:PIVONKA, DIANE MATILDA (MS, RN, APNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MATILDA
Last Name:PIVONKA
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Gender:F
Credentials:MS, RN, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1499 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2252
Mailing Address - Country:US
Mailing Address - Phone:920-497-6161
Mailing Address - Fax:920-498-0476
Practice Address - Street 1:1499 6TH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2252
Practice Address - Country:US
Practice Address - Phone:920-497-6161
Practice Address - Fax:920-498-0476
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1822-033364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41252600Medicaid