Provider Demographics
NPI:1790892081
Name:BALLERINO-REGAN, DIANE NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:NICOLE
Last Name:BALLERINO-REGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:NICOLE
Other - Last Name:BALLERINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-0679
Mailing Address - Country:US
Mailing Address - Phone:910-755-5260
Mailing Address - Fax:910-755-5263
Practice Address - Street 1:20 MEDICAL CAMPUS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4096
Practice Address - Country:US
Practice Address - Phone:910-755-5260
Practice Address - Fax:910-755-5263
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501169207V00000X
FLME00664057207V00000X
LA11076R207V00000X
CT033929207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01169OtherSC MCD PROVIDER ID#
NC12826OtherBCBS NC
NC8912826Medicaid
NCF66084Medicare UPIN
NC2218324CMedicare ID - Type UnspecifiedMCR PROVIDER ID#
SCN01169OtherSC MCD PROVIDER ID#