Healthcare Provider Details

I. General information

NPI: 1720004039
Provider Name (Legal Business Name): DIANE E DITO ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3000
  • Fax: 314-747-4876
Mailing address:
  • Phone: 314-747-3000
  • Fax: 314-747-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number141456
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: