Healthcare Provider Details

I. General information

NPI: 1619076239
Provider Name (Legal Business Name): DIANNE V. SEABAUGH CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PARK PL
SWANSEA IL
62226-2965
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-7500
  • Fax: 618-277-4236
Mailing address:
  • Phone: 314-851-1075
  • Fax: 314-851-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: