Provider Demographics
NPI:1083655815
Name:ACKROYD, DIANE MARIE (PMPNP-BC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:ACKROYD
Suffix:
Gender:F
Credentials:PMPNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 CAMPUS DR STE A245
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8630
Mailing Address - Country:US
Mailing Address - Phone:888-699-4873
Mailing Address - Fax:
Practice Address - Street 1:4255 CAMPUS DR STE A245
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-8630
Practice Address - Country:US
Practice Address - Phone:888-699-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400-600-1363LP0808X
CA95016167363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02205310Medicaid
NY2E2251Medicare PIN