=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932752037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNA LYNN HARTLEY CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 EAST RIVER ROAD
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-329-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39722 SMITH RD
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44275-9602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-592-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 024692
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.024692
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------