Provider Demographics
NPI:1366699985
Name:WAMBAUGH, DIANA JAYE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:JAYE
Last Name:WAMBAUGH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-1209
Mailing Address - Country:US
Mailing Address - Phone:208-336-1836
Mailing Address - Fax:
Practice Address - Street 1:1270 KOT-NUM RD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-1209
Practice Address - Country:US
Practice Address - Phone:208-336-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP 370A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily