Provider Demographics
NPI:1366105488
Name:CHURCH, DIANNE L (CRNP)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:L
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 WAGNER AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-3935
Mailing Address - Country:US
Mailing Address - Phone:814-403-7703
Mailing Address - Fax:
Practice Address - Street 1:100 PEACH ST STE 200
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1423
Practice Address - Country:US
Practice Address - Phone:814-877-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021459363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health