Healthcare Provider Details

I. General information

NPI: 1154480556
Provider Name (Legal Business Name): DIENNA LOUISE LANDIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIENNA LOUISE DICKSON CNP

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2249 ELM ROAD EXT
CORTLAND OH
44410
US

IV. Provider business mailing address

9394 ST RT 7
KINSMAN OH
44428
US

V. Phone/Fax

Practice location:
  • Phone: 330-372-1608
  • Fax: 330-372-1633
Mailing address:
  • Phone: 330-876-0709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP08479
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: