Provider Demographics
NPI:1740522101
Name:LIETZ, DIANE M (APRN FNP-C)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:LIETZ
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 WORRELL LN
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62694-3628
Mailing Address - Country:US
Mailing Address - Phone:217-371-2901
Mailing Address - Fax:
Practice Address - Street 1:800 W STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2290
Practice Address - Country:US
Practice Address - Phone:217-243-2292
Practice Address - Fax:217-243-5359
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily