Basic Information
Provider Information | |||||||||
NPI: | 1669513610 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RYLAND | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11225 | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374012225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238925602 | ||||||||
FaxNumber: | 4238925838 | ||||||||
Practice Location | |||||||||
Address1: | 2624 OAK RIDGE DR | ||||||||
Address2: |   | ||||||||
City: | ROCKY FACE | ||||||||
State: | GA | ||||||||
PostalCode: | 307409071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234883283 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2007 | ||||||||
LastUpdateDate: | 02/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN127990 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | RN091337 | GA | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | APN10810 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | N375502 | 01 | GA | WELLCARE (GA MEDICAID) | OTHER | P00213091 | 01 | TN | RAILROAD MEDICARE | OTHER | 4100326 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 935938084A | 05 | GA |   | MEDICAID | 3633933 | 05 | TN |   | MEDICAID |