Provider Demographics
NPI:1982883369
Name:CLAVEL, DIANE SODERHOLM (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:SODERHOLM
Last Name:CLAVEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 189S
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-5802
Mailing Address - Country:US
Mailing Address - Phone:651-332-7470
Mailing Address - Fax:651-332-7490
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 189S
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-5802
Practice Address - Country:US
Practice Address - Phone:651-332-7470
Practice Address - Fax:651-332-7490
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR098281-4363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500002207Medicare PIN