1558668632 NPI number — MRS. DIANE ELIZABETH ROBERTS CRNA

Table of content: MRS. DIANE ELIZABETH ROBERTS CRNA (NPI 1558668632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558668632 NPI number — MRS. DIANE ELIZABETH ROBERTS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
DIANE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENGE
Provider Other First Name:
DIANE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558668632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
58 DAISY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40744-6440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-312-3801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58 DAISY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40744-6440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-312-3801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  1080250 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 086603 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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