Provider Demographics
NPI:1558309526
Name:MCCONNEHEY, DIANE (DO)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MCCONNEHEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8638
Mailing Address - Country:US
Mailing Address - Phone:208-323-5580
Mailing Address - Fax:
Practice Address - Street 1:6650 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8738
Practice Address - Country:US
Practice Address - Phone:208-323-5625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31963Medicare UPIN