Provider Demographics
NPI:1841773645
Name:CHUNG, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CHUNG
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 1:540 S CIRCULO LAZO
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4302
Mailing Address - Country:US
Mailing Address - Phone:714-222-0558
Mailing Address - Fax:
Practice Address - Street 1:540 S CIRCULO LAZO
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4302
Practice Address - Country:US
Practice Address - Phone:714-222-0558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily