Provider Demographics
NPI:1871894808
Name:TACKIE, DIANE ADAKU (PA-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ADAKU
Last Name:TACKIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:TACKIE GRANILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:40 YORK RD STE 110
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-5243
Mailing Address - Country:US
Mailing Address - Phone:202-951-7942
Mailing Address - Fax:202-971-1991
Practice Address - Street 1:40 YORK RD STE 110
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5243
Practice Address - Country:US
Practice Address - Phone:202-951-7942
Practice Address - Fax:202-971-1991
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04246363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical