Healthcare Provider Details

I. General information

NPI: 1467485748
Provider Name (Legal Business Name): DIANE LIND FENSTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 DOUSMAN ST
GREEN BAY WI
54303-3211
US

IV. Provider business mailing address

PO BOX 19070 PREVEA HEALTH
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax: 920-436-1349
Mailing address:
  • Phone: 920-496-4700
  • Fax: 920-436-1349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: