Provider Demographics
NPI:1609381359
Name:BONECUTTER, DIANE MARIE (PCA)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:BONECUTTER
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:RICHIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2290 HANNAN TRACE ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25520
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:2290 HANNAN TRACE ROAD
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:WV
Practice Address - Zip Code:25520
Practice Address - Country:US
Practice Address - Phone:304-812-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0034008001OtherPROVIDER ID