Provider Demographics
NPI:1992571657
Name:WARREN, DIANE SYLVIA (TATTOO ARTIST)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SYLVIA
Last Name:WARREN
Suffix:
Gender:F
Credentials:TATTOO ARTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11943 NE 109TH WAY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3423
Mailing Address - Country:US
Mailing Address - Phone:360-936-7380
Mailing Address - Fax:
Practice Address - Street 1:201 NE PARK PLAZA DR STE 246
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5874
Practice Address - Country:US
Practice Address - Phone:360-936-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2417305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service