Provider Demographics
NPI:1568545283
Name:ETTER, DIANE N (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:N
Last Name:ETTER
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 COLONIAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3205
Mailing Address - Country:US
Mailing Address - Phone:540-342-1796
Mailing Address - Fax:
Practice Address - Street 1:2122 COLONIAL AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3205
Practice Address - Country:US
Practice Address - Phone:540-342-1796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101000741156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0130560001Medicare ID - Type UnspecifiedNON PARTICIPATING PROVIDE