Basic Information
| Provider Information | |||||||||
| NPI: | 1396289534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DINE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 S SAWBURG AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446015926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308231112 | ||||||||
| FaxNumber: | 3308231139 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 S SAWBURG AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446015926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308231112 | ||||||||
| FaxNumber: | 3308231139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | LE-00005218 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | LE-00005218 | 01 | OH | CNP | OTHER | AG1016083 | 01 | OH | AANP CERTIFICATION | OTHER |