Provider Demographics
NPI:1982049763
Name:BROSCHE, DIANE MARTINE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARTINE
Last Name:BROSCHE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GORDON COMMERCIAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5754
Mailing Address - Country:US
Mailing Address - Phone:706-845-4045
Mailing Address - Fax:
Practice Address - Street 1:52 PERRY ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1974
Practice Address - Country:US
Practice Address - Phone:678-423-4610
Practice Address - Fax:770-254-7419
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN081396163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse