Provider Demographics
NPI:1457345480
Name:CAPANNA, DIANE (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CAPANNA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PINEVIEW COURT
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1110
Mailing Address - Country:US
Mailing Address - Phone:586-776-7626
Mailing Address - Fax:
Practice Address - Street 1:201 PINEVIEW COURT
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1110
Practice Address - Country:US
Practice Address - Phone:586-776-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704082314367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104300444Medicaid
MIDC082314OtherBLUE CROSS OF MI
430062780Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MI104300444Medicaid