Provider Demographics
NPI:1609191667
Name:SOEM, DIANE (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SOEM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:KONESAVANH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:LAHEY CLINIC
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8132
Mailing Address - Fax:781-744-2273
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:LAHEY CLINIC
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8132
Practice Address - Fax:781-744-2273
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA271109367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001730904Medicare PIN