Provider Demographics
NPI:1871962589
Name:INDA, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:INDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIAN
Other - Middle Name:
Other - Last Name:INDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3417
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 MOUNT HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9066
Practice Address - Country:US
Practice Address - Phone:971-983-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2015005058363LP0808X
OR201801068NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500742223Medicaid