Provider Demographics
NPI:1700456720
Name:KOONCE, DIANA (LPN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KOONCE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 N 4220 RD
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-8513
Mailing Address - Country:US
Mailing Address - Phone:469-562-3713
Mailing Address - Fax:
Practice Address - Street 1:1139 N 4220 RD
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-8513
Practice Address - Country:US
Practice Address - Phone:469-562-3713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0069021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse