Provider Demographics
NPI:1407947179
Name:CONGDON, DIANA (APRN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CONGDON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 WHITNEY AVE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-1400
Mailing Address - Country:US
Mailing Address - Phone:203-407-1310
Mailing Address - Fax:
Practice Address - Street 1:1844 WHITNEY AVE STE 2
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517
Practice Address - Country:US
Practice Address - Phone:203-407-1310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1495363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4008405Medicaid