Provider Demographics
NPI:1205860756
Name:ST. PIERRE, DIANE (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:ST. PIERRE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51-53 KENOSIA AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810
Mailing Address - Country:US
Mailing Address - Phone:203-748-0330
Mailing Address - Fax:203-731-3273
Practice Address - Street 1:51-53 KENOSIA AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:03681
Practice Address - Country:US
Practice Address - Phone:203-748-0330
Practice Address - Fax:203-731-3273
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001051363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001051OtherCT STATE LICENSE NUMBER
CTMS0641426OtherFEDERAL DEA NUMBER
CTMS0641426OtherFEDERAL DEA NUMBER
CTP22790Medicare UPIN