Provider Demographics
NPI:1437267127
Name:MCNICKLE, DIANE R (CRNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:R
Last Name:MCNICKLE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-3128
Mailing Address - Country:US
Mailing Address - Phone:215-453-7613
Mailing Address - Fax:
Practice Address - Street 1:1425 HORSHAM RD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1320
Practice Address - Country:US
Practice Address - Phone:215-371-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP005852C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA062994Medicare PIN
PAP68724Medicare UPIN