Healthcare Provider Details

I. General information

NPI: 1104986330
Provider Name (Legal Business Name): DIANE LYNN DUNNIWAY NPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 NEWFIELD AVE
STAMFORD CT
06905-1409
US

IV. Provider business mailing address

1180 NEWFIELD AVE
STAMFORD CT
06905-1409
US

V. Phone/Fax

Practice location:
  • Phone: 314-888-5233
  • Fax:
Mailing address:
  • Phone: 314-888-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209004498
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: