Provider Demographics
NPI:1043429582
Name:GROGAN, DIANE ELAINE (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELAINE
Last Name:GROGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FORBES RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-4211
Mailing Address - Country:US
Mailing Address - Phone:617-710-9262
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST # 197
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194471363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health