Provider Demographics
NPI:1053643775
Name:VINES, DIANE (PHD, RN,)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:VINES
Suffix:
Gender:F
Credentials:PHD, RN,
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3880 SE 8TH AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3772
Mailing Address - Country:US
Mailing Address - Phone:503-819-4285
Mailing Address - Fax:
Practice Address - Street 1:3880 SE 8TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3772
Practice Address - Country:US
Practice Address - Phone:503-819-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200140577RN163WP0808X
CA198331364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200140577RNOtherR.N. LICENSE
CA198331OtherR.N. LICENSE AND PSYCH NURSE PRACTITIONER INACTIVE