Provider Demographics
NPI:1912767245
Name:SHOALS, DIANE ELIZABETH
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:SHOALS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 SUBURBAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4609
Mailing Address - Country:US
Mailing Address - Phone:651-705-0982
Mailing Address - Fax:651-204-2867
Practice Address - Street 1:2030 SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4609
Practice Address - Country:US
Practice Address - Phone:651-330-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility