Provider Demographics
NPI:1881647832
Name:ROOT-RACINE, DIANE H (ARNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:ROOT-RACINE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3045
Mailing Address - Country:US
Mailing Address - Phone:360-683-5900
Mailing Address - Fax:360-582-4800
Practice Address - Street 1:808 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-683-5900
Practice Address - Fax:360-582-4800
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60004129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9615790Medicaid
WARO9766OtherREGENCE DIANE ROOT-RACINE
WA101638OtherL&I DIANE ROOT-RACINE
WAS04394Medicare UPIN
WAAB11971Medicare ID - Type UnspecifiedDIANE ROOT-RACINE ARNP