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General NPI Number Information
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NPI Number | 1871538744
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Entity Type | Individual
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Provider Name | DIANE L HARTZOG CRNA
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Gender | Female
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 03/27/2008
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Provider Practice Location Address
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Address Line | 125 HOSPITAL DRIVE
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City | WATERTOWN
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State | WI
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Zip | 53098
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Country | US
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Telephone | 920-262-4450
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Fax |
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Provider Business Mailing Address
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Address Line | 4555 WEST SCHROEDER DRIVE SUITE 170
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City | MILWAUKEE
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State | WI
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Zip | 53223
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Country | US
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Telephone | 414-365-3210
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Fax | 414-365-3225
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367H00000X
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Taxonomy Name | Anesthesiologist Assistant
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License Number | 78920030
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License Number State | WI
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