Basic Information
| Provider Information | |||||||||
| NPI: | 1689074296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLTMAN | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RNFA, CNOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
| FaxNumber: | 2172582216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
| FaxNumber: | 2173423477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2014 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041316405 | IL | N | Nursing Service Providers | Registered Nurse | 163WM0705X | 041316405 | IL | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 163WR0006X | 041316405 | IL | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.