Healthcare Provider Details

I. General information

NPI: 1154324614
Provider Name (Legal Business Name): DIANE ANDERSON RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 CHARLES ST
DEADWOOD SD
57732-1303
US

IV. Provider business mailing address

71 CHARLES ST
DEADWOOD SD
57732-1303
US

V. Phone/Fax

Practice location:
  • Phone: 605-578-2364
  • Fax: 605-719-6470
Mailing address:
  • Phone: 605-578-2364
  • Fax: 605-719-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR012358
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: