Provider Demographics
NPI:1124225461
Name:CONKLIN, DIANNE M
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:CONKLIN
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 1:4909 S COAST HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97366-9667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4909 S COAST HWY STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEACH
Practice Address - State:OR
Practice Address - Zip Code:97366-9667
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator