Provider Demographics
NPI:1881778991
Name:LEASE, DIANNA H (APN)
Entity type:Individual
Prefix:MS
First Name:DIANNA
Middle Name:H
Last Name:LEASE
Suffix:
Gender:F
Credentials:APN
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:ATLANTICARE REGIONAL MEDICAL CENTER
Practice Address - Street 2:JIMMIE LEEDS RD.
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9104
Practice Address - Country:US
Practice Address - Phone:609-652-3599
Practice Address - Fax:609-652-3495
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNR08041700363L00000X, 363LN0000X, 363LN0005X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7294301Medicaid
MD4033191Medicaid
NJ7294301Medicaid