Healthcare Provider Details

I. General information

NPI: 1710282678
Provider Name (Legal Business Name): DIANE K WALKER RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3144 VANZILE ROAD
CRANDON WI
54520-0275
US

IV. Provider business mailing address

1 N HILL ROAD
WAUSAU WI
54403
US

V. Phone/Fax

Practice location:
  • Phone: 715-478-5180
  • Fax: 715-478-5904
Mailing address:
  • Phone: 715-478-5180
  • Fax: 715-478-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number90435 30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: