Provider Demographics
NPI:1124271598
Name:BICKLE, DIANE MICHELE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MICHELE
Last Name:BICKLE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:4311 RAFTER B AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7308
Mailing Address - Country:US
Mailing Address - Phone:602-809-6364
Mailing Address - Fax:
Practice Address - Street 1:2202 N STOCKTON HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4622
Practice Address - Country:US
Practice Address - Phone:928-681-8706
Practice Address - Fax:928-861-8707
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2757363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ596098Medicaid