Provider Demographics
NPI:1063815454
Name:SLOUGH, DIANE BERRY (FNP-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:BERRY
Last Name:SLOUGH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:BEVERLY DIANE
Other - Middle Name:B
Other - Last Name:BOEWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1257
Mailing Address - Country:US
Mailing Address - Phone:573-629-3440
Mailing Address - Fax:573-629-3416
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3440
Practice Address - Fax:573-629-3416
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014035654363LF0000X
MO118370163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO118370OtherRN LICENSE
MO2014035654OtherFAMILY NURSE PRACTITIONER