Provider Demographics
NPI:1073582672
Name:HEASLEY, DIANE DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:DAWN
Last Name:HEASLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CONTINENTAL PL
Mailing Address - Street 2:STE 400
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1073
Mailing Address - Country:US
Mailing Address - Phone:615-916-3200
Mailing Address - Fax:615-658-8389
Practice Address - Street 1:6116 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-5703
Practice Address - Country:US
Practice Address - Phone:303-512-0888
Practice Address - Fax:303-512-2288
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35520207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ641789Medicaid
NMZ7622Medicaid
CO01355205Medicaid
UTZ0237Medicaid
CO220024532Medicare PIN
UTZ0237Medicaid
COC220338Medicare PIN