Provider Demographics
NPI:1447379359
Name:DIFFENBACHER, NANCY (CNP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:DIFFENBACHER
Suffix:
Gender:
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MARLOWE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4320
Mailing Address - Country:US
Mailing Address - Phone:216-226-4957
Mailing Address - Fax:
Practice Address - Street 1:23425 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5844
Practice Address - Country:US
Practice Address - Phone:216-831-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166572163W00000X
OHAPRN.CNP.02802363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2204831Medicaid
P13213Medicare UPIN
OH2204831Medicaid