Provider Demographics
NPI:1972744654
Name:DECILLIS JOHNSTON, DIANE (APRN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DECILLIS JOHNSTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 TOWER AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1273
Mailing Address - Country:US
Mailing Address - Phone:860-714-2750
Mailing Address - Fax:860-714-8591
Practice Address - Street 1:933 BRADBURY DR SE STE 2222
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4375
Practice Address - Country:US
Practice Address - Phone:505-365-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP54774363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTPENDINGMedicaid
CTPENDINGMedicaid