Provider Demographics
NPI:1093931917
Name:BUNCELPN, DIANE (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BUNCELPN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LAZY WATER DR SW
Mailing Address - Street 2:
Mailing Address - City:EUHARLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-5934
Mailing Address - Country:US
Mailing Address - Phone:770-375-5069
Mailing Address - Fax:
Practice Address - Street 1:218 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3628
Practice Address - Country:US
Practice Address - Phone:770-386-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN049647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse