Provider Demographics
NPI:1235428830
Name:PAUL, DIANE SAMS (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:SAMS
Last Name:PAUL
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 W FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2635
Mailing Address - Country:US
Mailing Address - Phone:209-546-7764
Mailing Address - Fax:209-546-7785
Practice Address - Street 1:1429 W FREMONT ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2635
Practice Address - Country:US
Practice Address - Phone:209-546-7764
Practice Address - Fax:209-546-7785
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20351363LF0000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20351Medicaid
CA20351Medicaid