Provider Demographics
NPI:1639160344
Name:FENLASON, DIANE R (FNP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:R
Last Name:FENLASON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:MOLLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15504 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1111
Mailing Address - Country:US
Mailing Address - Phone:703-878-2528
Mailing Address - Fax:
Practice Address - Street 1:15504 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:VA
Practice Address - Zip Code:22025-1111
Practice Address - Country:US
Practice Address - Phone:703-878-2528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA016985M58Medicare PIN