MEDICARE: MRS. DIANE R. GRAYBILL KEHOE FNP

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	363L00000X	Nurse Practitioner	209002308	IL
2	363LF0000X	Family Nurse Practitioner	209002308	IL
3	363L00000X	Nurse Practitioner	6775	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0040030712	OTHER	IL	BC/BS

General Provider Information

NPI Number	:	1942210604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE R. GRAYBILL KEHOE FNP

Provider Business Mailing Address
First Line	:	515 22ND AVENUE
Second Line	:
City	:	MONROE
State	:	WI
Zip	:	53566-1569
Country	:	US
Telephone Number	:	312-996-8009
Fax Number	:	312-996-7725

Provider Business Practice Location Address
First Line	:	100 W 8TH ST
Second Line	:
City	:	MONROE
State	:	WI
Zip	:	53566-1021
Country	:	US
Telephone Number	:	608-324-1940
Fax Number	:

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/16/2025

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