Provider Demographics
NPI:1184956690
Name:ANNIBALINI, DIANE PACKARD (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:PACKARD
Last Name:ANNIBALINI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:O6 SAINT MARC CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-4141
Mailing Address - Country:US
Mailing Address - Phone:860-682-3950
Mailing Address - Fax:
Practice Address - Street 1:384 MERROW RD STE K
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3970
Practice Address - Country:US
Practice Address - Phone:860-871-8851
Practice Address - Fax:860-871-8852
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002348363AM0700X
CT2348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002348OtherCT LICENSE NUMBER