Provider Demographics
NPI:1790233203
Name:GRESSETT, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GRESSETT
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 1:3608 ITHACA TRL
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2218
Mailing Address - Country:US
Mailing Address - Phone:757-871-2242
Mailing Address - Fax:
Practice Address - Street 1:3408 BART ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3231
Practice Address - Country:US
Practice Address - Phone:757-966-5902
Practice Address - Fax:757-673-6320
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16738174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174898506Medicaid