Provider Demographics
NPI:1376819235
Name:DIZON, NATALIE DIANE (CNP)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:DIANE
Last Name:DIZON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:DIZON
Other - Last Name:DOHENY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-8515
Practice Address - Fax:508-334-6490
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277680363L00000X, 363LA2200X
PASP012072363L00000X
AZAP4437363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093091AMedicaid
MA110093091AMedicaid
AZZ175387Medicare PIN