Healthcare Provider Details

I. General information

NPI: 1871662478
Provider Name (Legal Business Name): DIANE PANTELIS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BELMONT AVE
YOUNGSTOWN OH
44504-1003
US

IV. Provider business mailing address

1001 BELMONT AVE
YOUNGSTOWN OH
44504-1003
US

V. Phone/Fax

Practice location:
  • Phone: 330-747-6446
  • Fax: 330-746-6843
Mailing address:
  • Phone: 330-747-6446
  • Fax: 330-746-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP02840
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA02840NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: