Provider Demographics
NPI:1154480556
Name:LANDIS, DIENNA LOUISE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:DIENNA
Middle Name:LOUISE
Last Name:LANDIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:DIENNA
Other - Middle Name:LOUISE
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:9394 ST RT 7
Mailing Address - Street 2:
Mailing Address - City:KINSMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44428
Mailing Address - Country:US
Mailing Address - Phone:330-876-0709
Mailing Address - Fax:
Practice Address - Street 1:2249 ELM ROAD EXT
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410
Practice Address - Country:US
Practice Address - Phone:330-372-1608
Practice Address - Fax:330-372-1633
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08479363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2631996Medicaid
OHLANP20061Medicare ID - Type Unspecified
G61267Medicare UPIN