Provider Demographics
NPI:1083914832
Name:DIAMOND, IDA RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:RENEE
Last Name:DIAMOND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:RENEE
Other - Last Name:FICHTENHOLZ-DIAMOND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:1701 W FM 646 RD
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4968
Mailing Address - Country:US
Mailing Address - Phone:281-337-5430
Mailing Address - Fax:281-337-5148
Practice Address - Street 1:1701 W FM 646 RD
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4968
Practice Address - Country:US
Practice Address - Phone:281-337-5430
Practice Address - Fax:281-337-5148
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily