Provider Demographics
NPI:1972666071
Name:HARRELL, DIANE A (MED)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 GWINETTE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1615
Mailing Address - Country:US
Mailing Address - Phone:478-742-5629
Mailing Address - Fax:
Practice Address - Street 1:2817 GWINETTE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1615
Practice Address - Country:US
Practice Address - Phone:478-742-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD000959237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA64BCBLLMedicare PIN