Provider Demographics
NPI:1972002681
Name:ROBERTS, DIANNA (PCA)
Entity Type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 DUDDING AVENUE
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526
Mailing Address - Country:US
Mailing Address - Phone:304-562-5029
Mailing Address - Fax:
Practice Address - Street 1:550 DUDDING AVENUE
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:304-562-5029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G23810001681OtherPROVIDER ID