Provider Demographics
NPI:1942210604
Name:GRAYBILL KEHOE, DIANE R (FNP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:R
Last Name:GRAYBILL KEHOE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:PINEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:515 22ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1569
Mailing Address - Country:US
Mailing Address - Phone:312-996-8009
Mailing Address - Fax:312-996-7725
Practice Address - Street 1:100 W 8TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1021
Practice Address - Country:US
Practice Address - Phone:608-324-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002308363L00000X, 363LF0000X
WI6775363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0040030712OtherBC/BS
IL0040030712OtherBC/BS
ILS80966Medicare UPIN