Basic Information
| Provider Information | |||||||||
| NPI: | 1417131038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWBRE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | GNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PURCELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730804220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055274704 | ||||||||
| FaxNumber: | 4054275976 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PURCELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730804220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055274704 | ||||||||
| FaxNumber: | 4054275976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 547215 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LG0600X | 49456 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 20053303A | 05 | OK | MEDICAID |