Healthcare Provider Details

I. General information

NPI: 1366105488
Provider Name (Legal Business Name): DIANNE L CHURCH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 10/15/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PEACH ST STE 200
ERIE PA
16507-1423
US

IV. Provider business mailing address

3913 WAGNER AVE
ERIE PA
16510-3935
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-7733
  • Fax:
Mailing address:
  • Phone: 814-403-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP021459
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: