Healthcare Provider Details

I. General information

NPI: 1174983472
Provider Name (Legal Business Name): MRS. DIANA OHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA ROTH

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 02/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1909
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-320-7680
  • Fax: 570-326-8151
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP015978
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: