Provider Demographics
NPI:1578900791
Name:REAGLE, DIANE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:REAGLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 E GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3597
Mailing Address - Country:US
Mailing Address - Phone:918-850-2233
Mailing Address - Fax:877-777-2249
Practice Address - Street 1:604 E GLENDALE ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-3597
Practice Address - Country:US
Practice Address - Phone:918-850-2233
Practice Address - Fax:877-777-2249
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKROO49723163WA2000X
OKR0049723163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health