Provider Demographics
NPI:1982828489
Name:PUPPOLO, DIANE H (APRN)
Entity Type:Individual
Prefix:MISS
First Name:DIANE
Middle Name:H
Last Name:PUPPOLO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 PADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7044
Mailing Address - Country:US
Mailing Address - Phone:203-630-5314
Mailing Address - Fax:
Practice Address - Street 1:883 PADDOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7044
Practice Address - Country:US
Practice Address - Phone:203-630-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000847364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT890000489OtherMED ID TYPE UNSPECIFIED