Healthcare Provider Details

I. General information

NPI: 1942626098
Provider Name (Legal Business Name): CHANDRA DEE DIEBOLD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E BRADY ST SUITE 103
BUTLER PA
16001-4648
US

IV. Provider business mailing address

806 HAY ST
FAYETTEVILLE NC
28305-5312
US

V. Phone/Fax

Practice location:
  • Phone: 724-282-1627
  • Fax: 724-282-4810
Mailing address:
  • Phone: 910-860-7008
  • Fax: 910-221-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number276761
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP013734
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: