Provider Demographics
NPI:1386122687
Name:GWINN, DIANA ELIZABETH (DD1)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ELIZABETH
Last Name:GWINN
Suffix:
Gender:F
Credentials:DD1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16405 NE FARGO CIR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5513
Mailing Address - Country:US
Mailing Address - Phone:503-484-7287
Mailing Address - Fax:503-210-5974
Practice Address - Street 1:16405 NE FARGO CIR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5513
Practice Address - Country:US
Practice Address - Phone:503-484-7287
Practice Address - Fax:503-210-5974
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10465311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500745787Medicaid