Provider Demographics
NPI:1679518187
Name:SCHLICK, DIANE A (DO)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:A
Last Name:SCHLICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:A
Other - Last Name:HAISTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:616 S JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32347
Mailing Address - Country:US
Mailing Address - Phone:850-584-5876
Mailing Address - Fax:850-584-4939
Practice Address - Street 1:616 S JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347
Practice Address - Country:US
Practice Address - Phone:850-584-5876
Practice Address - Fax:850-584-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
47095OtherBLUE CROSS BLUE SHIELD
FLOS7860OtherMEDICAL LICENSE
E2588Medicare PIN
FLOS7860OtherMEDICAL LICENSE