Basic Information
| Provider Information | |||||||||
| NPI: | 1053790030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURRELL | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAY | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 358 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049370358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074534708 | ||||||||
| FaxNumber: | 2074536250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 BENTON AVE | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049013327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074534708 | ||||||||
| FaxNumber: | 2074536250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2015 | ||||||||
| LastUpdateDate: | 05/25/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN24397 | ME | N | Nursing Service Providers | Registered Nurse | 251E00000X | Y | Agencies | Home Health |
No ID Information.