Basic Information
| Provider Information | |||||||||
| NPI: | 1255529962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 SHERMAN DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027485041 | ||||||||
| FaxNumber: | 8027485094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 1010021194 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1014206 | 05 | VT | MEDICAID |