Provider Demographics
NPI:1225180425
Name:STACK, DIANE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WEYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-6044
Mailing Address - Country:US
Mailing Address - Phone:860-745-6102
Mailing Address - Fax:
Practice Address - Street 1:36 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4533
Practice Address - Country:US
Practice Address - Phone:860-763-5669
Practice Address - Fax:860-763-5664
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE45917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse