Provider Demographics
NPI:1902192099
Name:SMITH, DIANE C (APRN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:C
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:901 SW GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1670
Mailing Address - Country:US
Mailing Address - Phone:785-354-9591
Mailing Address - Fax:785-354-0497
Practice Address - Street 1:901 SW GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1670
Practice Address - Country:US
Practice Address - Phone:785-354-9591
Practice Address - Fax:785-354-0497
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75097-122363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002123OtherMEDICARE PTAN
KS200732530AMedicaid