Provider Demographics
NPI:1518185388
Name:MAYTHORNE, DIANNE K B (ANP)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:K B
Last Name:MAYTHORNE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1049
Mailing Address - Street 2:
Mailing Address - City:WILLOW
Mailing Address - State:AK
Mailing Address - Zip Code:99688-1049
Mailing Address - Country:US
Mailing Address - Phone:907-733-2273
Mailing Address - Fax:
Practice Address - Street 1:1363 W SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-5327
Practice Address - Country:US
Practice Address - Phone:907-376-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17770163WH0200X
AK1223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1912011842OtherAGENCY NPI NUMBER
AKNP0193Medicaid
AKHH2487Medicaid
AKNA2487Medicaid
AKPCG214Medicaid
AKPCG214Medicaid
AKNP0193Medicaid