Provider Demographics
NPI:1316991854
Name:VANDOVER, DIANE M (NP)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:VANDOVER
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Gender:F
Credentials:NP
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Mailing Address - Street 1:88 E NEWTON ST
Mailing Address - Street 2:SPECIAL PROCEDURES- BOSTON MEDICAL CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2308
Mailing Address - Country:US
Mailing Address - Phone:617-838-6642
Mailing Address - Fax:617-414-8801
Practice Address - Street 1:88 E NEWTON ST
Practice Address - Street 2:SPECIAL PROCEDURES- BOSTON MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-838-6642
Practice Address - Fax:617-414-8801
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MA193344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0349160Medicaid
MA0349160Medicaid
MAP02851Medicare UPIN