Provider Demographics
NPI:1972578474
Name:BRACKIN, DIANA LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LOUISE
Last Name:BRACKIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S JACKSON PARK DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2626
Mailing Address - Country:US
Mailing Address - Phone:812-519-2963
Mailing Address - Fax:812-519-3515
Practice Address - Street 1:600 S JACKSON PARK DR
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2626
Practice Address - Country:US
Practice Address - Phone:812-519-2963
Practice Address - Fax:812-519-3515
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001567A363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200537140Medicaid
IN000000652123OtherANTHEM
IN153883Medicare Oscar/Certification
Q56031Medicare UPIN
IN000000652123OtherANTHEM