Provider Demographics
NPI:1417592908
Name:WOLSTENHOLME, DIANE (CRNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WOLSTENHOLME
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:WOLSTENHOLME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-5030
Mailing Address - Fax:215-707-3494
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5189
Practice Address - Country:US
Practice Address - Phone:215-707-5030
Practice Address - Fax:215-707-3494
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021119363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily