Provider Demographics
NPI:1104062074
Name:WINTZER, DIANE SUSAN (LAC, EAMP)
Entity type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:SUSAN
Last Name:WINTZER
Suffix:
Gender:F
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 NE CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2144
Mailing Address - Country:US
Mailing Address - Phone:360-851-4268
Mailing Address - Fax:844-244-8288
Practice Address - Street 1:430 NE CEDAR ST
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2144
Practice Address - Country:US
Practice Address - Phone:360-851-4268
Practice Address - Fax:844-244-8288
Is Sole Proprietor?:No
Enumeration Date:2008-12-26
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60055845171100000X
ORAC01249171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist