Provider Demographics
NPI:1851550776
Name:CONNELL, DIANA (RN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:505-759-3291
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO179402163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NMHSZ196OtherMEDICARE PART B