Provider Demographics
NPI:1114078847
Name:HACKETT, DIANA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:HACKETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:L
Other - Last Name:BARBERIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2157 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-6983
Mailing Address - Country:US
Mailing Address - Phone:304-699-4103
Mailing Address - Fax:
Practice Address - Street 1:2157 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-699-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0067524000Medicaid
WV0207026000OtherGROUP MEDICAID
WV9333201OtherMEDICARE GROUP
WV9333201OtherMEDICARE GROUP