Provider Demographics
NPI:1699207795
Name:ROTT, DIANE ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:ROTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1601
Mailing Address - Country:US
Mailing Address - Phone:608-475-1107
Mailing Address - Fax:
Practice Address - Street 1:504 GREEN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1601
Practice Address - Country:US
Practice Address - Phone:608-475-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI85696163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse