Provider Demographics
NPI:1649226556
Name:ABBOTT, DIANE C (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3950 KRESGE WAY
Practice Address - Street 2:SUITE 207
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-893-0220
Practice Address - Fax:502-893-0563
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000506A363L00000X
KY3008600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487280Medicaid
KY7100348350Medicaid
IN200487280Medicaid