Healthcare Provider Details

I. General information

NPI: 1528065489
Provider Name (Legal Business Name): DIANE M. REILLY C.R.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 HIGHLAND AVE
FALL RIVER MA
02720-3703
US

IV. Provider business mailing address

340 MAIN STREET SUITE 670
WORCESTER MA
01608-1681
US

V. Phone/Fax

Practice location:
  • Phone: 508-679-3131
  • Fax: 508-679-7146
Mailing address:
  • Phone: 508-754-3566
  • Fax: 508-798-8012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number141280
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: