Provider Demographics
NPI:1013137520
Name:PANKOW, DIANE AGNES (APRN-BC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:AGNES
Last Name:PANKOW
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2132
Mailing Address - Country:US
Mailing Address - Phone:781-784-8197
Mailing Address - Fax:
Practice Address - Street 1:1071 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-2302
Practice Address - Country:US
Practice Address - Phone:617-333-2182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA149936363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care