Provider Demographics
NPI:1932550050
Name:SASSOS, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:SASSOS
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:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-0137
Mailing Address - Country:US
Mailing Address - Phone:603-286-8200
Mailing Address - Fax:
Practice Address - Street 1:16 COFRAN AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NH
Practice Address - Zip Code:03276-1606
Practice Address - Country:US
Practice Address - Phone:603-286-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03032171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH04-3665237OtherEIN