Basic Information
| Provider Information | |||||||||
| NPI: | 1548454770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALDERMAN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 648 NORTH H STREET | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058651940 | ||||||||
| FaxNumber: | 8058651941 | ||||||||
| Practice Location | |||||||||
| Address1: | 648 NORTH H STREET | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058651940 | ||||||||
| FaxNumber: | 8058651941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN563807 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | RN563807 | 01 | CA | REGISTERED NURSE | OTHER |