Provider Demographics
NPI:1023407335
Name:DY, DIANE MAE ROSE SY (CRNA)
Entity type:Individual
Prefix:
First Name:DIANE MAE ROSE
Middle Name:SY
Last Name:DY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64795
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4795
Mailing Address - Country:US
Mailing Address - Phone:410-328-6704
Mailing Address - Fax:410-328-4124
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6704
Practice Address - Fax:410-328-4124
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DE104871367500000X
MDR175780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered