Provider Demographics
NPI:1447226915
Name:CROLL, DIANE ROSE (APRN)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ROSE
Last Name:CROLL
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 1:9 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1909
Mailing Address - Country:US
Mailing Address - Phone:203-459-2495
Mailing Address - Fax:
Practice Address - Street 1:600 BOND ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2205
Practice Address - Country:US
Practice Address - Phone:203-384-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002827363LF0000X
CT2827363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004257417Medicaid
CT500001558Medicare PIN
CT004257417Medicaid
CTQ54077Medicare UPIN