Provider Demographics
NPI:1952840647
Name:ROCHE, DIANE LYNN (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LYNN
Last Name:ROCHE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2654
Mailing Address - Country:US
Mailing Address - Phone:423-543-2584
Mailing Address - Fax:423-722-2060
Practice Address - Street 1:1500 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-543-2584
Practice Address - Fax:423-722-2060
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA3209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029831Medicaid