Healthcare Provider Details

I. General information

NPI: 1467648360
Provider Name (Legal Business Name): DIANE ALINE THEWS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MORTHLAND DR
VALPARAISO IN
46383-8329
US

IV. Provider business mailing address

3355 DOUGLAS RD SUITE 300
SOUTH BEND IN
46635-1781
US

V. Phone/Fax

Practice location:
  • Phone: 800-635-5516
  • Fax:
Mailing address:
  • Phone: 574-647-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002126A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: