Provider Demographics
NPI:1780481978
Name:WETMORE, DIANE LOUISE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:WETMORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 TRAVERS CIR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3751
Mailing Address - Country:US
Mailing Address - Phone:574-334-6373
Mailing Address - Fax:
Practice Address - Street 1:728 TRAVERS CIR
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3751
Practice Address - Country:US
Practice Address - Phone:574-334-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001175A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist