Healthcare Provider Details

I. General information

NPI: 1962403345
Provider Name (Legal Business Name): DIANA LEE MULDER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA ANTONICH MULDER CRNP

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
BOARDMAN OH
44512-6725
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-7633
  • Fax: 330-729-7656
Mailing address:
  • Phone: 330-729-7633
  • Fax: 330-729-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA.10363-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: