Provider Demographics
NPI:1902364292
Name:SAWERS-VIDAL, DIANNE (APRN)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:SAWERS-VIDAL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9560
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:8725 N WICKHAM RD STE 200
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2240
Practice Address - Country:US
Practice Address - Phone:321-434-9560
Practice Address - Fax:321-434-9269
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLE342OtherMEDICARE
FL102902500Medicaid