Healthcare Provider Details

I. General information

NPI: 1477032571
Provider Name (Legal Business Name): DIANA PEMBERTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 W 15TH ST STE 1025
PLANO TX
75075-7253
US

IV. Provider business mailing address

165 TOUCHSTONE RD
WYLIE TX
75098
US

V. Phone/Fax

Practice location:
  • Phone: 972-673-0404
  • Fax: 469-626-9670
Mailing address:
  • Phone: 214-738-8560
  • Fax: 469-626-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number650434
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: