Provider Demographics
NPI:1194797449
Name:PROKUPEK, DIANNA MARIE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:MARIE
Last Name:PROKUPEK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 EAST 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC
Mailing Address - State:IA
Mailing Address - Zip Code:50022
Mailing Address - Country:US
Mailing Address - Phone:712-243-2606
Mailing Address - Fax:712-243-2688
Practice Address - Street 1:1408 EAST 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022
Practice Address - Country:US
Practice Address - Phone:712-243-2606
Practice Address - Fax:712-243-2688
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG087587363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0464800Medicaid
4551902Medicare ID - Type Unspecified
IA0464800Medicaid