Provider Demographics
NPI:1508965377
Name:PTACNIK, DIANE (LVN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PTACNIK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-2912
Mailing Address - Country:US
Mailing Address - Phone:951-272-1444
Mailing Address - Fax:
Practice Address - Street 1:999 BURR ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-4018
Practice Address - Country:US
Practice Address - Phone:951-737-8802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN118836164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN001390OtherPROVIDER NUMBER