Provider Demographics
NPI:1467632356
Name:SMITH, DIANA BOWERS
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:BOWERS
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 6
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVER
Mailing Address - State:WV
Mailing Address - Zip Code:26815
Mailing Address - Country:US
Mailing Address - Phone:304-249-5172
Mailing Address - Fax:
Practice Address - Street 1:108 WALNUT ST
Practice Address - Street 2:PENDLETON COUNTY BOARD OF EDUCATION
Practice Address - City:FRANKLIN
Practice Address - State:WV
Practice Address - Zip Code:26807-0888
Practice Address - Country:US
Practice Address - Phone:304-358-2207
Practice Address - Fax:304-358-2936
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165858000Medicaid