Provider Demographics
NPI:1396841540
Name:BARRY, DIANE MAE JEROME (DC)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MAE JEROME
Last Name:BARRY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 UPPER HEATHER AVE N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8310
Mailing Address - Country:US
Mailing Address - Phone:651-429-4047
Mailing Address - Fax:
Practice Address - Street 1:1526 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2227
Practice Address - Country:US
Practice Address - Phone:651-690-9366
Practice Address - Fax:651-690-4736
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3422111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN231957OtherCHIROCARE
MN44-42579OtherMEDICA
MN53971700OtherMEDICAL ASSISTANCE
MN0140OtherHEA;TH SERVICE MANAGEMENT
MN5C183JEOtherB:UE CROSS