Healthcare Provider Details

I. General information

NPI: 1144399387
Provider Name (Legal Business Name): DIANE NEDDENRIEP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 E FARNESS DR STE. 111A
TUCSON AZ
85712-2158
US

IV. Provider business mailing address

5155 E FARNESS DR STE. 111A
TUCSON AZ
85712-2158
US

V. Phone/Fax

Practice location:
  • Phone: 520-327-1787
  • Fax: 520-321-9613
Mailing address:
  • Phone: 520-327-1787
  • Fax: 520-321-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number17428
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: