Provider Demographics
NPI:1063721975
Name:BOOTH, DIANE MARIE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:TREMBLAY
Other - Last Name:DISALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:550 POPE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:913-684-6000
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-64943-052163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse