Provider Demographics
NPI:1063544385
Name:PEASE, DIANE SUSAN (MS,FNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SUSAN
Last Name:PEASE
Suffix:
Gender:F
Credentials:MS,FNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:SUSAN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:453 MOUNTAIN VIEW RD SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-8537
Mailing Address - Country:US
Mailing Address - Phone:706-234-2956
Mailing Address - Fax:706-291-4006
Practice Address - Street 1:18 RIVERBEND DR SW
Practice Address - Street 2:SUITE 230
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6013
Practice Address - Country:US
Practice Address - Phone:706-291-2999
Practice Address - Fax:706-291-4006
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHBQMedicare ID - Type Unspecified
GAB34617Medicare UPIN