Provider Demographics
NPI:1659493161
Name:CRIDENNDA, DIANE K (LAC)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:CRIDENNDA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1422 N HANCOCK AVE
Mailing Address - Street 2:SUITE 5 S
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2641
Mailing Address - Country:US
Mailing Address - Phone:719-520-5056
Mailing Address - Fax:719-520-5222
Practice Address - Street 1:1422 N HANCOCK AVE
Practice Address - Street 2:SUITE 5 S
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2641
Practice Address - Country:US
Practice Address - Phone:719-520-5056
Practice Address - Fax:719-520-5222
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO337171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO337OtherCOLORADO STATE LICENCE