Provider Demographics
NPI:1851827380
Name:CARPENTER, DIANE RUTH (LPN-21303)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RUTH
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:LPN-21303
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:RUTH
Other - Last Name:WALIKAINEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN-21303
Mailing Address - Street 1:2201 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7570
Mailing Address - Country:US
Mailing Address - Phone:505-801-4905
Mailing Address - Fax:
Practice Address - Street 1:2201 E 11TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7570
Practice Address - Country:US
Practice Address - Phone:505-801-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPN21303376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide