Healthcare Provider Details

I. General information

NPI: 1255484952
Provider Name (Legal Business Name): DIANE B LUEDTKE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N 12TH ST
LEHIGHTON PA
18235-1138
US

IV. Provider business mailing address

9 WHITE LN
JIM THORPE PA
18229-1022
US

V. Phone/Fax

Practice location:
  • Phone: 570-401-3960
  • Fax: 570-325-8336
Mailing address:
  • Phone: 570-325-4170
  • Fax: 570-325-8336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberTP006236C
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberTP006235H
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: