Healthcare Provider Details

I. General information

NPI: 1396713798
Provider Name (Legal Business Name): DIANE P LANDSTAD N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

IV. Provider business mailing address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-2157
  • Fax: 218-927-4130
Mailing address:
  • Phone: 218-927-2157
  • Fax: 218-927-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR050374-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: