Provider Demographics
NPI:1619165008
Name:PERRY, DIANE LYNNETTE (NP C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNNETTE
Last Name:PERRY
Suffix:
Gender:F
Credentials:NP C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:LYNNETTE
Other - Last Name:GOLKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 N 3RD ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2135
Mailing Address - Country:US
Mailing Address - Phone:602-496-0721
Mailing Address - Fax:602-496-0675
Practice Address - Street 1:500 N 3RD ST
Practice Address - Street 2:SUITE 155
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2135
Practice Address - Country:US
Practice Address - Phone:602-496-0721
Practice Address - Fax:602-496-0675
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2706363LF0000X
AZAP2709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ125057OtherPTAN MEDICARE