Provider Demographics
NPI:1881847184
Name:MACMILLAN, DIANE JEAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JEAN
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5103
Mailing Address - Country:US
Mailing Address - Phone:215-707-8366
Mailing Address - Fax:215-707-1649
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-8366
Practice Address - Fax:215-707-1649
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP-004421-C363LA2200X
NJ26NN07392400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily