Provider Demographics
NPI:1922384841
Name:KEARNEY, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 COLVER AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3808
Mailing Address - Country:US
Mailing Address - Phone:888-578-3457
Mailing Address - Fax:860-405-0760
Practice Address - Street 1:60 COLVER AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3808
Practice Address - Country:US
Practice Address - Phone:888-578-3457
Practice Address - Fax:860-405-0760
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist