Provider Demographics
NPI:1629126388
Name:DEHAVEN, DIANNE MARIE (MS, CNS, ARNP)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:MARIE
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:MS, CNS, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:513-354-5200
Practice Address - Street 1:1501 MADISON RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1706
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS-03911364SP0808X, 363L00000X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241045Medicaid
OH2968598Medicaid
OH2968598Medicaid
KY00472004Medicare PIN