Provider Demographics
NPI:1093785529
Name:BENNETT, DIANE M
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:BENNETT
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 1:200 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:WI
Mailing Address - Zip Code:53820-9413
Mailing Address - Country:US
Mailing Address - Phone:608-763-2744
Mailing Address - Fax:
Practice Address - Street 1:2140 JFK RD
Practice Address - Street 2:STE F
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-3883
Practice Address - Country:US
Practice Address - Phone:563-582-0769
Practice Address - Fax:563-582-5772
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist