Provider Demographics
NPI:1780786533
Name:DRAKE, DIANE ZADRA (APRN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ZADRA
Last Name:DRAKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ZADRA
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-0677
Mailing Address - Country:US
Mailing Address - Phone:785-242-3780
Mailing Address - Fax:785-242-6397
Practice Address - Street 1:2537 EISENHOWER RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-9482
Practice Address - Country:US
Practice Address - Phone:785-242-3780
Practice Address - Fax:785-242-6397
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSAPRN 53-74199-102364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100337790AMedicaid
KS44812Medicare ID - Type UnspecifiedMEDICARE
KS100337790AMedicaid