Provider Demographics
NPI:1477589497
Name:EASTRIDGE, DIANA (NP-FAMILY)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:EASTRIDGE
Suffix:
Gender:F
Credentials:NP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22741 SUNNYSIDE GULCH RD
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-6059
Mailing Address - Country:US
Mailing Address - Phone:608-512-3855
Mailing Address - Fax:
Practice Address - Street 1:451 JUNCTION RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2656
Practice Address - Country:US
Practice Address - Phone:608-263-8915
Practice Address - Fax:608-265-5755
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI169519363L00000X
SDCP002090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner