Basic Information
| Provider Information | |||||||||
| NPI: | 1376544155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLIS | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192942233 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 TARHE TRL | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433518700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192941525 | ||||||||
| FaxNumber: | 4192090252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-07907 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | NP-07907 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000527473 | 01 | OH | ANTHEM BCBS | OTHER | 0947033 | 05 | OH | MEDICAID | 2545759 | 05 | OH | MEDICAID |