Provider Demographics
NPI:1275542656
Name:POAGE, DIANE (MS CCC-SLP/A)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:POAGE
Suffix:
Gender:F
Credentials:MS CCC-SLP/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16643 YELLOWSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9407
Mailing Address - Country:US
Mailing Address - Phone:907-276-5055
Mailing Address - Fax:
Practice Address - Street 1:16643 YELLOWSTONE CIR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-9407
Practice Address - Country:US
Practice Address - Phone:907-276-5055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
AKSP0194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist