Provider Demographics
NPI:1699525147
Name:WARD, DIANE ROSE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ROSE
Last Name:WARD
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3111
Mailing Address - Country:US
Mailing Address - Phone:218-398-0335
Mailing Address - Fax:218-999-0214
Practice Address - Street 1:1107 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2205
Practice Address - Country:US
Practice Address - Phone:218-326-0095
Practice Address - Fax:218-999-0214
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2458666163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse