Healthcare Provider Details

I. General information

NPI: 1558669929
Provider Name (Legal Business Name): DIANE MARY CUMMINS RN, CCDC IIIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 S. EDWIN C MOSES BLVD.
DAYTON OH
45417
US

IV. Provider business mailing address

921 S EDWIN C MOSES BLVD.
DAYTON OH
45417
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-1376
  • Fax: 937-341-8198
Mailing address:
  • Phone: 937-461-1376
  • Fax: 937-341-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number892645
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN-149812
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: