Provider Demographics
NPI:1467556886
Name:KRAYNAK, DIANE E (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:KRAYNAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-381-8840
Mailing Address - Fax:704-381-8848
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:MEDICAL CENTER PLAZA, SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:704-381-8848
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164861363LP0200X
KS75151363LP0200X
MO2010023280364SP0200X
NC5006032363LP0200X
NC258783363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006614Medicaid
VA010271932 541581185Medicaid
SCNP2319Medicaid
NC1467556886Medicaid
NC1467556886Medicaid
Q61834Medicare UPIN
VA010271932 541581185Medicaid