Provider Demographics
NPI:1891728408
Name:WADDELL, DIANE E (NP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:E
Last Name:WADDELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5514 CORPORATE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-7754
Mailing Address - Country:US
Mailing Address - Phone:816-271-7169
Mailing Address - Fax:
Practice Address - Street 1:5514 CORPORATE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-7754
Practice Address - Country:US
Practice Address - Phone:816-271-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO121001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200265100AMedicaid
MO10001677501OtherCOMMUNITY HEALTH PLAN
MO201060639Medicaid
701C970Medicare ID - Type Unspecified
Q10145Medicare UPIN