Provider Demographics
NPI:1669012076
Name:O'BRIEN, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HIGHLAND TER
Mailing Address - Street 2:
Mailing Address - City:IVORYTON
Mailing Address - State:CT
Mailing Address - Zip Code:06442-1136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 HIGHLAND TER
Practice Address - Street 2:
Practice Address - City:IVORYTON
Practice Address - State:CT
Practice Address - Zip Code:06442-1136
Practice Address - Country:US
Practice Address - Phone:860-767-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider