Provider Demographics
NPI:1699158196
Name:BLOCK, DIANE DENISE (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:DENISE
Last Name:BLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:DENISE
Other - Last Name:SITARSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1345 SMIZER MILL RD STE 1100
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7305
Practice Address - Country:US
Practice Address - Phone:636-496-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015013958363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015013958OtherLICENSE