Provider Demographics
NPI:1922429794
Name:LALLEY, DIANE E (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:E
Last Name:LALLEY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5998 N US HIGHWAY 41 STE A
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3133
Mailing Address - Country:US
Mailing Address - Phone:813-751-3570
Mailing Address - Fax:813-641-9001
Practice Address - Street 1:5998 N US HIGHWAY 41 STE A
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-3133
Practice Address - Country:US
Practice Address - Phone:813-751-3570
Practice Address - Fax:813-641-9001
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-22
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9273761363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108461900Medicaid
NCNCN435DMedicare PIN
NCNCN435AMedicare PIN
NC1922429794Medicaid
NCNCN435BMedicare PIN
NCNCN435CMedicare PIN