Healthcare Provider Details

I. General information

NPI: 1184809139
Provider Name (Legal Business Name): DIANE JANE WILLGING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE JANE WILLGING RNC WHNP

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-5362
US

IV. Provider business mailing address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-5362
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-5300
  • Fax: 763-755-5301
Mailing address:
  • Phone: 763-755-5300
  • Fax: 763-755-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberWIL-0428-3281
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: