Provider Demographics
NPI:1124550157
Name:WAKELYN, DIANA (LPN)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:WAKELYN
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 1:2927 PLAYER AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-6601
Mailing Address - Country:US
Mailing Address - Phone:321-848-3713
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-9950
Practice Address - Fax:520-533-6712
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5192025164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse