Provider Demographics
NPI:1629358593
Name:GILLILAND, DIANE LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LEE
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 WESTERN AVE
Mailing Address - Street 2:STE A
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-1347
Mailing Address - Country:US
Mailing Address - Phone:419-423-2754
Mailing Address - Fax:419-423-7357
Practice Address - Street 1:15840 MEDICAL DR S
Practice Address - Street 2:SUITE B
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-7833
Practice Address - Country:US
Practice Address - Phone:419-425-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12553-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053936Medicaid
OHH033260Medicare PIN