Provider Demographics
NPI:1366452617
Name:DALLY, DIANA L (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:DALLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 TRUMP RD
Mailing Address - Street 2:P.O. BOX 38
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615
Mailing Address - Country:US
Mailing Address - Phone:330-627-7055
Mailing Address - Fax:330-627-7602
Practice Address - Street 1:1020 TRUMP RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615
Practice Address - Country:US
Practice Address - Phone:330-627-7055
Practice Address - Fax:330-627-7602
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188084363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2468155Medicaid
OHNP16431Medicare PIN
OH2468155Medicaid