Provider Demographics
NPI:1619763380
Name:WILSON, DIANE RAE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:RAE
Last Name:WILSON
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 1:60805 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-5901
Mailing Address - Country:US
Mailing Address - Phone:760-974-5990
Mailing Address - Fax:
Practice Address - Street 1:60805 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-5901
Practice Address - Country:US
Practice Address - Phone:760-974-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator