Provider Demographics
NPI:1871662478
Name:PANTELIS, DIANE (CNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PANTELIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1003
Mailing Address - Country:US
Mailing Address - Phone:330-747-6446
Mailing Address - Fax:330-746-6843
Practice Address - Street 1:1001 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1003
Practice Address - Country:US
Practice Address - Phone:330-747-6446
Practice Address - Fax:330-746-6843
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP02840363LA2200X
OHCOA02840NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2200522Medicaid
OHH112251Medicare UPIN