Provider Demographics
NPI:1003686387
Name:COLEY, DIANNE
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:COLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 REESE DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-4614
Mailing Address - Country:US
Mailing Address - Phone:757-405-7322
Mailing Address - Fax:
Practice Address - Street 1:3055 REESE DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-4614
Practice Address - Country:US
Practice Address - Phone:757-405-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver