Healthcare Provider Details

I. General information

NPI: 1295760668
Provider Name (Legal Business Name): DIANA LYNNE COLASSESANO R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 THOMPSON DR
BRIDGEPORT WV
26330-1644
US

IV. Provider business mailing address

166 THOMPSON DR
BRIDGEPORT WV
26330-1644
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-6001
  • Fax: 304-842-6111
Mailing address:
  • Phone: 304-842-6001
  • Fax: 304-842-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD1100X
TaxonomyPeritoneal Dialysis Registered Nurse
License Number61413
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: