Provider Demographics
NPI:1619205614
Name:WHITE, DIANE ELAINE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELAINE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 PAUL BUNYAN DR NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2439
Mailing Address - Country:US
Mailing Address - Phone:218-497-1040
Mailing Address - Fax:218-497-0363
Practice Address - Street 1:716 PAUL BUNYAN DR NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2439
Practice Address - Country:US
Practice Address - Phone:218-497-1040
Practice Address - Fax:218-497-0363
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor