Healthcare Provider Details

I. General information

NPI: 1043018567
Provider Name (Legal Business Name): DIANA CONCANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 VAN BUREN CIR
GOFFSTOWN NH
03045-2423
US

IV. Provider business mailing address

87 VAN BUREN CIR
GOFFSTOWN NH
03045-2423
US

V. Phone/Fax

Practice location:
  • Phone: 857-888-3988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN2391540
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number089504-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: