Provider Demographics
NPI:1073591285
Name:SMITH, DIANE RUTH
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RUTH
Last Name:SMITH
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 1:1016 S WAYNE ST
Mailing Address - Street 2:#612
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-4433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:238 BROOKLEY AVE.
Practice Address - Street 2:
Practice Address - City:BOLLING AFB
Practice Address - State:DC
Practice Address - Zip Code:20332-0001
Practice Address - Country:US
Practice Address - Phone:202-404-3603
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001040494363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health