Provider Demographics
NPI:1942265749
Name:ROBERTS, DIANE LESLIE (PCNS)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LESLIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 LAKESIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2314
Mailing Address - Country:US
Mailing Address - Phone:401-781-0085
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER, MHBSS
Practice Address - Street 2:830 CHALKSTONE AVENUE
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4799
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:401-457-3371
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00060363LP0808X
RI26915163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI46301Medicare UPIN