Provider Demographics
NPI:1417965765
Name:GRASSO, DIANE E (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:GRASSO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:E
Other - Last Name:TELLIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:MA
Mailing Address - Zip Code:01331-2117
Mailing Address - Country:US
Mailing Address - Phone:978-249-0099
Mailing Address - Fax:978-249-7227
Practice Address - Street 1:201 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-2117
Practice Address - Country:US
Practice Address - Phone:978-249-0099
Practice Address - Fax:978-249-7227
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191199207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000224901Medicare UPIN