Basic Information
| Provider Information | |||||||||
| NPI: | 1518185388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYTHORNE | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | K. B. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1049 | ||||||||
| Address2: | |||||||||
| City: | WILLOW | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996881049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077332273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1363 W SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | WASILLA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996545327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073762411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | 17770 | AK | N | Nursing Service Providers | Registered Nurse | Home Health | 363LF0000X | 1223 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1912011842 | 01 | AK | AGENCY NPI NUMBER | OTHER | NP0193 | 05 | AK | MEDICAID | HH2487 | 05 | AK | MEDICAID | NA2487 | 05 | AK | MEDICAID | PCG214 | 05 | AK | MEDICAID |