Provider Demographics
NPI:1285372078
Name:BERTHA, DIANE LYNN
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:BERTHA
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 1:3854 MARION DR
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5245
Mailing Address - Country:US
Mailing Address - Phone:304-748-0596
Mailing Address - Fax:
Practice Address - Street 1:3854 MARION DR
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5245
Practice Address - Country:US
Practice Address - Phone:304-748-0596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1356607394Medicaid
WV1821206228Medicaid