Provider Demographics
NPI:1912912395
Name:WHALEY, DIANE WADE (ABOC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:WADE
Last Name:WHALEY
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 AIRLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5915
Mailing Address - Country:US
Mailing Address - Phone:318-747-9227
Mailing Address - Fax:
Practice Address - Street 1:2353 AIRLINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5810
Practice Address - Country:US
Practice Address - Phone:318-747-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5781570001Medicare NSC