Provider Demographics
NPI:1205896560
Name:FRUIT, DIANE G (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:G
Last Name:FRUIT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-3190
Mailing Address - Fax:508-368-3985
Practice Address - Street 1:123 SUMMER STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-368-3190
Practice Address - Fax:508-368-3985
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA89813363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA3464OtherHARVARD PILGRIM HEALTHCAR
NP0989OtherBLUE SHIELD INDEMNITY
042472266OtherPRIVATE HEALTHCARE SYSTEM
381317OtherMVP HEALTH CARE
NP0989OtherBLUE SHIELD HMO BLUE
MA0324094Medicaid
56649OtherCHILDRENS MEDICAL SECURIT
57172OtherFALLON COMMUNITY HEALTH P
NP0989OtherMEDICARE B
ME0324094Medicaid
8301165OtherEVERCARE
NP0989OtherBLUE CARE ELECT
042472266OtherTHREE RIVERS
ME0324094Medicaid
MA0324094Medicaid