Provider Demographics
NPI:1720438542
Name:MOORE, DIANE (STNA)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 BARCLAY SQ W
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-1129
Mailing Address - Country:US
Mailing Address - Phone:614-313-7832
Mailing Address - Fax:
Practice Address - Street 1:454 BARCLAY SQ W
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-1129
Practice Address - Country:US
Practice Address - Phone:614-313-7832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X
OH401669780714376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker