Provider Demographics
NPI:1134174220
Name:TODD, DIANE H (ACNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:TODD
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4578
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4578
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350035NPACNPPP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-0635514OtherNBMC GROUP TAX ID FOR BILLING
OR1407812365OtherNBMC GROUP NPI
ORR0000WFBTVOtherNBMC GROUP MEDICARE
OR161133OtherNBMC GROUP MEDICAID
OR028112Medicaid