Provider Demographics
NPI:1588043632
Name:CULBERTSON, DIANA LYNN (PA)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:CULBERTSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL
Mailing Address - Street 2:CB 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6051
Mailing Address - Fax:314-454-6225
Practice Address - Street 1:1 CHILDRENS PL STE C
Practice Address - Street 2:STE C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6051
Practice Address - Fax:314-454-6225
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015006221208000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics