Provider Demographics
NPI:1386708089
Name:WOOLLUM, DIANA JEAN (MN, ARNP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:JEAN
Last Name:WOOLLUM
Suffix:
Gender:F
Credentials:MN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-473-0637
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:780 SWIFT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3545
Practice Address - Country:US
Practice Address - Phone:509-942-3060
Practice Address - Fax:509-946-1850
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007073363L00000X, 363LF0000X
WARN00127488363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9646209Medicaid
WA9646209Medicaid
WAG8856890Medicare PIN
WA8865634Medicare PIN