MEDICARE: DIANE MARIE GORA REGISTERED NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WL0100X	Lactation Consultant (Registered Nurse)	28062518A	IN

General Provider Information

NPI Number	:	1164742540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MARIE GORA REGISTERED NURSE

Provider Business Mailing Address
First Line	:	1400 S LAKE PARK AVE STE 205
Second Line	:
City	:	HOBART
State	:	IN
Zip	:	46342-6791
Country	:	US
Telephone Number	:	219-942-8620
Fax Number	:	219-942-6356

Provider Business Practice Location Address
First Line	:	1400 S LAKE PARK AVE STE 205
Second Line	:
City	:	HOBART
State	:	IN
Zip	:	46342-6791
Country	:	US
Telephone Number	:	219-942-8620
Fax Number	:	219-942-6356

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2010
Last Update Date	:	06/08/2010

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