Provider Demographics
NPI:1619130077
Name:SEEBOCK, DIANA L (GNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:SEEBOCK
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:SEEBOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, MSN
Mailing Address - Street 1:3033 KETTERING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1948
Mailing Address - Country:US
Mailing Address - Phone:937-293-2133
Mailing Address - Fax:
Practice Address - Street 1:3033 KETTERING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1948
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:937-293-2161
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.06613-NP363LF0000X
OHCOA06613-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS1431500185OtherCARE SOURCE
OH000000877722OtherANTHEM
OH0105748Medicaid
OH000000877722OtherANTHEM