Provider Demographics
NPI:1356595466
Name:EASTLICK, DIANNA (CANP)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:EASTLICK
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10685 99TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-3471
Mailing Address - Country:US
Mailing Address - Phone:763-315-8776
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2008005175363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health