Basic Information
| Provider Information | |||||||||
| NPI: | 1982686440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | SABO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RNC,ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 W 5TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 W 5TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 11269.056 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 110391101 | 05 | WY | MEDICAID | 11269.056 | 01 | WY | STATE LICENSE NUMBER | OTHER | MM0193045 | 01 | WY | DEA NUMBER | OTHER | 0437320 | 05 | MT | MEDICAID |