=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245505767
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE MARIE O'LAUGHLIN RN, PHN, FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2012
-----------------------------------------------------
Last Update Date | 08/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9260 LAGUNA SPRINGS DR
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95758-7947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-294-0706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4038
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95812-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-294-0706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 500006
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 21967
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WS0200X
-----------------------------------------------------
Taxonomy Name | School Registered Nurse
-----------------------------------------------------
License Number | 30239486
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------